INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8, 2006 through November 9, 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 December 12, 2006.
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
There was no documentation that alternate exit routes were utilized during fire drills.
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Plan of Correction
705.28(d)(5)Fire Safety
Alternate exit routes will be included in documentation of all fire drill reports completed by safety officer. Fire drill reports will be reviewed by the Executive Director with the safety officer. Staff training is provided by the safety officer for all staff on utilization of alternate exit routes for emergencies, including fire drills. Executive Director will monitor for on-going compliance with this. |
709.26(a)(11) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(11) Employe accidents and safety.
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Observations
The policy and procedure did not identify who was responsible for correcting safety issues.
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Plan of Correction
Policy #709.26(a)(11) is revised to read: Employee accidents and safety.
ARS holds the deepest concern for the health, safety and welfare of its staff. The organization has developed emergency response plans to ensure safety, emergency evacuation routes, an infection control plan, and incident/risk identification and reporting. The Executive Director has the responsibility for correcting safety issues. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
The policy regarding employee rights did not include the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the personnel record.
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Plan of Correction
Policy # 709.26(e)(2) is revised and states the following: Each employee also has the right to inspect his or her own records, request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the personnel record. |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
The policy regarding employee rights did not include the employee's right to submit rebuttal data or memoranda to his or her own records.
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Plan of Correction
Policy #709.26(e)(3) is revised and written as follows: Each employee has the right to submit rebuttal data or memoranda for the personnel record. |
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
Information was released without a written consent by the client in one of six records reviewed, #5.
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Plan of Correction
709.28(c) Confidentiality. Staff training has been conducted on compliance with confidentiality procedures by Executive Director. Random monthly chart audits are conducted by the clinical supervisor to ensure compliance with completion of signed consent by client with any accompanying disclosure of client information. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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
Treatment plans were missing in two of ten client records , #4 and 9. Treatment plans were not completed within the time frame identified by the facility's policy in three of eight client records reviewed , #1, 3 and 7.
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Plan of Correction
709.92 Treatment and rehabilitation services. Clinician staff training completed by Executive Director on compliance timeline for completion of required documents for client medical record. Medical record is subject to random monthly audits performed by clinical supervisor. Any deficiencies will be discussed with clinical supervisor and clinician responsible. Clinical supervisor is responsible for on going staff training on compliance with client medical record documentation. |
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
Treatment plan updates were missing in three of seven client records reviewed, #8, 10 and 12.
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Plan of Correction
709.92(b) Treatment plans and rehabilitation services. Staff clinician training provided by Executive Director on compliance with required documentation for client medical record. Medical record is subject to random monthly audits performed by clinical supervisor to ensure timely completion of required medical record documentation. Deficiencies will be discussed with responsible clinician. Clinical supervisor will provide staff training to ensure compliance with required medical record documentation on an as needed basis. |