INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10, 2006 to July 13, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 7, 2006.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The water temperature for the 400 house was 165 degrees. The water temperature for the 500 house was 150 degrees. The water temperature at the women's residential unit was 150 degrees. Hot water temperatures may not exceed 120 degrees Fahrenheit.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The lavatory on the right side of the second floor of the 500 house does not have an exhaust fan and the window is inoperable. There is no ventilation in this lavatory.
The exhaust fan is inoperable in the lavatory located near the counselors' offices on the women's residential unit. There is no ventilation in this lavatory.
The counseling office for the detoxification activity and the nurse practitioner's office share a shower room and have sperate rooms with toilets. The shower room has a window, but the rooms with the toilets do not have windows or exhaust fans. When the doors to the shower room are closed, there is no ventilation. Room 107 and 107A are set up in a similar manner. In order for these lavatories to be functional, they each need to have proper ventilation either through an operable window or exhaust fan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(8) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Record of services provided.
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Observations
Client record # 1 and 4 did not have a record of services and client record # 2 did not include individual sessions on the record of services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(2) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(2) Utilization of volunteers.
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Observations
The policy and procedure manual does not include a policy and procedure for the utilization of volunteers.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
The policy on employee rights does not include the employee's right to inspect his own records.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
The agency policy does not include the client's right to request the removal of inaccurate, irrelevant, outdated, or incomplete information from his record.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Client records for the detoxification level of care did not include psychosocial evaluations.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.63(a)(5) LICENSURE Record of Services
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(5) Record of services provided.
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Observations
Record of services fail to include documentation of the individual treatment sessions provided.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations in client records # 5, 6, 7 and 8 were not completed and documented within the time frames stipulated in the facility policy and procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(3) LICENSURE Records of Service
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
The records of services in client records #4, 6, 7 and 8 failed to consistently include documentation of all of the individual sessions provided.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Client record # 2 and 4 did not assess the client's progress relative to the goals stated on the treatment plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Case consultations were missing in client record # 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |