INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on May 8, 2006.
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Plan of Correction
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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
Individual training plans were missing in three (#4, #5, and #7) of twenty records reviewed. Several training plans were not based on the employee's needs.
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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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Employee #1 was missing documentation of having received the department approved TB/STD training hours.
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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
Documentation for sexual history only explored current sexual identity and comfort zone, and did not explore any past or present sexual experiences. Documentation of the family history consisted of minimal information. This is in one of one client records reviewed. In particular, client record #18.
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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
The psychosocial evaluation was primarily a repeat of the historical data obtained rather than the counselor's assessment of the data in one (#18) of one client record reviewed.
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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(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Client record #14 did not have any current medical information, but rather the medical history from a prior admission. All client records reviewed contained current medical information only and did not address past medical problems.
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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(b)(3)(ii) LICENSURE Intake and admission
709.91. 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
The drug and alcohol history was obtained during a prior admission of more than six months ago in client record #14.
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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(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal history was obtained during a prior admission of more than six months ago. This was in client record #14. In addition, the family and sexual histories in client records # 15, #16 and #17 contained minimal information, and sometimes one-word answers.
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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(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations were a repeat of the historical data rather than an evaluative summary of the data in four (#14, #15, #16 and #17) of four client records reviewed.
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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 |