INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2006 to May 12, 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 June 15, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
An assessment of staff training needs was not documented in personnel files for the two employees reviewed.
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Plan of Correction
An approved 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
An individual training plan was not completed for two employees reviewed.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
There were staff who did not have the fire extinguisher training within the mandated timeframe. All staff must have instruction on fire extinguisher use within seven days of the date of employment.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Documentation of fire drills for the past year was incomplete. Fire drills must be conducted and documented at least monthly.
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Plan of Correction
An approved 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
There were staff who did not have the emergency procedure training within the mandated timeframe. All staff must have instruction on emergency procedures within seven days of the date of employment with the agency.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Employee #15 did not have references documented in their personnel file.
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Plan of Correction
An approved 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
A re-disclosure statement included in the consent to release form implies that once the information is released to the other party, confidentiality laws protecting that information may no longer apply. Although the facility giving the information is not responsible if the recipient re-releases the information once they have made them aware that it is illegal, the information is always protected. This form gives inaccurate information to the client. This form was found in all client charts reviewed.
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Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |