INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 17, 2006 through April 21, 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 19, 2006.
|
Plan of Correction
|
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Traffic area and group room carpets are stained and need to be replaced or cleaned.
|
Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Fire drill documentation for the months of 11/2005, 12/2005, 1/2006, 2/2006 and 3/2006 did not include evacuation time or alarm system status at the time of the drills.
|
Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
One of four personal files reviewed did not have a performance evaluation annually.
|
Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
|
Observations
Sample medications are not stored as defined in established organizational policies.
|
Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
|
Observations
Case consultations were not completed in three of fifteen client files reviewed.
|
Plan of Correction
An approved Plan of Correction is on file with the Department of Health. |