INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 6 through 7, 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 October 4, 2006.
|
Plan of Correction
|
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Documentation that a fire alarm or smoke detector was set off during each fire drill was not provided.
|
Plan of Correction
Deficiency was reviewed with all staff on September 11, 2006. Staff persons involved in documentation of the fire drills will note as of October 1, 2006 on all future log entries that a fire alarm or smoke detector was set off during each fire drill and the status of operation of that equipment during each drill. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Follow up information was not documented as per facility policy in two of four client records reviewed, #7 and 9.
|
Plan of Correction
The deficiency was initially reviewed in staff meeting with all staff on September 11, 2006. On September 25, 2006, we will be providing a staff review of the policy and the proper documentation as it pertains to follow-up information. We will also be doing random checks of files throughout the year to assess continued compliance with this policy/regulation. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Employee #2 has not received 4 hours of TB/STD training.
|
Plan of Correction
As of September 11, 2006, the agency will begin to look for upcoming TB/STD trainings. We will send this staff person to the next available training in our area with the goal of completion of this training by 11/30/06. Copies of that training will be documented in the employee's individual training plan. |