INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2006 to May 20, 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 June 15, 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
Documentation did not demonstrate the use of alternate exits during fire drills. The exit routes used need to be documented in the fire drill record.
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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 annual report was not made available to the public in a timely manner. Documentation must occur within six months of the end of the fiscal year. The 2004-2005 annual report was not made available to the general public until after December 31, 2005.
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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
Treatment models were not defined in the policy and procedure manual. Definitions of each treatment model used should be included. Documentation of client services should be consistent with the conceptual treatment model.
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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. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The audit must be completed within six months of the end of the fiscal year. The 04-05 audit was not completed until April, 2006 or 10 months from 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. |
709.28(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
Each file reviewed contained a consent to release information attached to the client sign off on the HIPAA requirements. This form was not completed in accordance with applicable laws in any of the records reviewed, and consequently, did not meet the requirements for an informed consent.
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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)(6) 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:
(6) Expiration date of the consent.
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Observations
Expiration dates were missed on consents in files # 3 and 7. Expiration date should reflect time, date, event or condition depending upon the nature of the information disclosed.
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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. |