INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5 - 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 July 10, 2006.
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Plan of Correction
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705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
There are no smoke detectors in the office suite.
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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. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
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Observations
Documentation of follow-up is missing in chart #9.
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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. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The 2004-2005 annual report was not completed.
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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. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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:
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Observations
Releases of information were not signed prior to the disclosure of information in charts #3,
#8, & #9. In chart #3, when the facility refers for adjunct services within the Familylinks system, a release of information is to be signed that allows for the disclosure of information. The exception to this is if the adjunct service staff is listed as staff on page 7 of the facility summary report, clearly identifying that staff as facility support staff.
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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. |