INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10-11, 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 June 12, 2007.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The project failed to provide completed documentation listing all staff associated with the drug and alcohol treatment program.
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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. |
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.
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Observations
Training plans were missing for employee #1 and 5, and the training plan for employee #2 was incomplete as it only addressed 6 hrs training on the training plan.
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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. |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to maintain freezer temperature at or below at or below 0 degree Fahrenheit. The thermometer in the freezer of the refrigerator was registering at 10 degrees Fahrenheit.
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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. |
705.28 (c) (2) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
The fire extinguisher is not located away from the cooking area, but is directly across from the convection ovens.
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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. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 document that all personnel on all shifts are trained to perform assigned tasks in emergency.
Facility staff failed to evacuate when the smoke detector went off during the onsite visit.
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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. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
The facility failed to vary the times of drills. There were no drills conducted beyond 12:45 PM and the facility operates until 9:00 PM.
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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. |
709.81(a)(1) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
The facility failed to develop a written plan for the criteria for admission.
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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. |
709.81(a)(2) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
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Observations
The facility failed to develop a written plan regarding their treatment methodology.
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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. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Medical histories were completed late, according to facility policy, in two of three records reviewed, #1 & 3.
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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. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and alcohol histories were completed late, according to facility policy, in two of three records reviewed, #1 & 3.
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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. |
709.81(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.
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Observations
Personal histories were completed late, according to facility policy, in two of three records reviewed, #1 & 3.
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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. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were late, according to facility policy, in two of three records reviewed, #1 & 3.
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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. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The treatment plan for one of three records reviewed, #1, was completed before the histories and the psychosocial evaluation were completed.
The treatment plan was also completed according to facility policy.
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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. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to consistently provide individual treatment two times per week for two out of three client records reviewed, #1 & 2.
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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)(9) 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:
(9) Progress notes.
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Observations
Group notes did not contain individualized assessments for client records #1, 2 & 3.
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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 facility failed to have the annual report completed and available to the public within six months of the end of the fiscal year.
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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. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
The facility failed to provide documentation that the board reviewed and approved the policies in 2006.
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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. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The facility failed to present Project Goals & Objectives to the Governing Body for the 2006 - 2007 year.
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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. |
709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
The facility failed to identify treatment models utilized by the project in the policy manual.
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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. |
709.24(a)(4) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers.
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Observations
The facility failed to clearly define in writing what the policy and procedures for incoming and out going referrals is.
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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. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
The facility failed to have a written policy regarding the administration and/or storage of medication used by the clients.
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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. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
The facility failed to develop a written plan for the criteria for admission.
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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. |
709.91(a)(2) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(2) Treatment methodology.
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Observations
The facility failed to develop a written plan regarding the treatment methodology.
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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. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
One of five client records reviewed, # 5, was missing treatment plan updates.
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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. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Progress note assessments were not individualized in two of six client records reviewed, #5 and 8.
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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. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case Consultations were either missing or lacked specific summaries and dispositions
in three of five client records reviewed: missing in client record #5, lacked specific summaries and dispositions in client records #7 & 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. |