INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2006 through October 11, 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 November 7, 2006.
709.14 Restriction on License (a)(5) Authorized capacity.
On October 11, 2006, the facility had 21 clients for residential treatment activity which exceeds the authorized maximum capacity of 20 .
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Plan of Correction
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
The physician's signature was not dated for verbal medication orders. Therefore, it could not be determined if verbal orders were signed within 24 hours from the time the order was given.
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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. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
A handrail was missing on the stairway leading down to the group room/client lounge area in the basement. A handrail was missing in the first floor fire tower/exit next to the client dormitory section of the building.
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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. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
None of the client bedrooms had any safety screens or security locks on the windows.
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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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations did not include a composite picture of the client and the client's coping mechanisms in two of five client records reviewed, # 1 and 8. The psychosocial evaluations did not assess the potential impact of the client's support systems and negative factors that may inhibit treatment in four of five client records reviewed, # 1, 2, 3 and 4.
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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. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The treatment plan updates did not include a review the reason(s) why the counselor believed that goals have not been achieved in two of five records reviewed, # 1 and 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. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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
The assessment portion of the progress notes did not contain interpretative statement(s) and/or the counselor's analysis and conclusions in four of five client records reviewed, # 1, 2, 4 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. |