INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2007 to January 24, 2007 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 February 16, 2007.
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Plan of Correction
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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.
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Observations
Neither the fire alarms nor the smoke detectors were set off during fire drills on the following months: 1/07, 11/06, 10/06, 9/06, 8/06, and 4/06. A fire alarm or smoke detector must be activated during each drill unless the Department has approved an alternative procedure in writing.
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Plan of Correction
The fire alarm and/or smoke detectors will be activated for each monthly fire drill conducted.
The project Director and or the Facility Director would be responsible for either directly activating this alarm or designating someone to activate the alarm for each fire drill. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Out of fifteen client records reviewed, three (client records # 1, 2, and 6) did not include the type and frequency of the client's prescribed medications. All medications being taken by a client whether prescribed by the project's physician, or the client's private physician, should be recorded in the client record indicating the name of the drug, the dosage, and the frequency of use.
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Plan of Correction
This information is found in the medical chart as well as in the clinical chart. Unfortunately in the clinical chart the type and frequency of the medication was not listed on the bio psycho social questionnaire.
This form has been changed to include the type and frequency of prescribed medication. This was completed by the facility director.
In order to reassure that this will not reoccur when the facility director or another SMS staff member audits the clinical charts, the auditor will be responsible for ascertaining that this information is filled out completely. If the information is not completed the chart would be returned to the counselor with the instructions for the counselor to complete this information with the patient at next patient contact. |