INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12 through 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 May 19, 2006.
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Cigarette butts were found in the side yard area, near the playground area for the children.
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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 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
The sink and toilet were not working in the client bathroom on the second floor.
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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 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
All bathtubs have shower units. The bathtubs did not have slip resistant surfaces.
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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 |
711.51(b)(3)(iii) LICENSURE Personal History
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The family history/origin was not addressed in all records reviewed. Also, the employment history did not list all major jobs in records #1, 2 and 3.
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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 |
711.51(b)(5) LICENSURE Physical Examination
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Physical exams were missing in records # 2, 4 and 7. Vital signs were missing in record # 1. The temperature and respirations were missing in records #3 and 5.
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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 |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were missing in records #1 and 3. Defense mechanisms were missing in records # 2, 4 and 5.
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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 |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Treatment plan updates were missing in records #4 and 5.
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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 |
711.52(e) ELEMENT Provision of services
711.52. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Services were not provided as per the treatment plan due to progress notes missing from 1-06 to 4-06.
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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 |
711.52(f) LICENSURE Regular/scheduled Services
711.52. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Services were not provide on a regular and scheduled basis since progress notes were missing from 1-06 to 4-06.
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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 |
711.52(g)(5) LICENSURE Educational Support Services
711.52. Treatment and rehabilitation services.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
The letter of agreement was not current.
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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 |
711.51.(g)(6) LICENSURE Vocational Support Services
711.52. Treatment and rehabilitation services.
(g) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
The letter of agreement was not current.
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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 |
711.53(a) LICENSURE Client Record
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
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Observations
The client records were not complete due to many documents missing in all 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 |
711.53(a)(4) LICENSURE Progress Notes
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Individual and groups notes were missing in all records for the period of 1-06 to 4-06.
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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 |
711.53(a)(8) LICENSURE Work as Therapy
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(8) Verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan.
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Observations
Work therapy was not documented in records # 2 and 3.
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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 |
711.53(c)(2)(vi) LICENSURE Consent's Expiration Date
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(vi) The expiration date of the consent.
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Observations
The expiration date was missing on consent forms in records # 1, 2, 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 |
711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Whether or not a copy of the consent was offered to the client was not documented on forms in records #1, 2, 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 |
711.58(a)(3) LICENSURE Inspection of Storage Area
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
The last twelve months of inspection documentation could not be found during the licensing inspection.
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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 |