INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on July 17 through 18, 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 August 13, 2007.
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Plan of Correction
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to provide documentation that employee #3 was instructed in the use of the fire extinguishers.
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Plan of Correction
Program director will have a staff training for the #3 who is in need of fire safety and the use of fire extinguishers by 8/31/2007 |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to provide documentation that employee #3 was trained to perform assigned tasks during emergencies.
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Plan of Correction
Program director will train # 3 on how to perform assigned tasks in the event of a fire or other emergencies by 8/31/2007. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) 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
The facility failed to demonstrate that a copy of client consents were offered to client's in two of four client records reviewed, #1 and 2.
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Plan of Correction
Program director will go over the policy (at the staff meeting on August 13) that requires a copy of client consents be offered to the client as well as clients initialing his acceptance or rejection of the offer of the copy. Program director will also check on each counselors forms to be sure there is a place for the client to initial it for his acceptance or rejection of the copy. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The physical examination was missing in one of four client records reviewed, #3.
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Plan of Correction
Program director will meet with all counselors and intake coordinator and go over our policy with regard to physical examinations being completed and in our possession before allowing a student to enter our program. Program director will also remind them of the need (policy) to place these exams in the students file. (and keep them there) |