INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 5, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on May 8, 2006.
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Individual training plans were missing in three (#4, #5, and #7) of twenty records reviewed. Several training plans were not based on the employee's needs.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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 #1 was missing documentation of having received the department approved TB/STD training hours.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Documentation of the client's sexual history only explored current sexual identity and comfort zone, and did not explore any past or present sexual experiences. The recreation/leisure history was missing in one of one client record reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluation was primarily a repeat of the historical data obtained rather than the counselor's assessment of the data in one (#3) of one client record reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Documentation of the client's sexual history only explored current sexual identity and comfort zone, and did not explore any past or present sexual experiences. The recreation/leisure history was missing in one of two client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The psychosocial evaluation was a repeat of the historical data rather than the counselor's assessment of the data in one (#4) of two client records reviewed.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |