INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25 and 26, 2007 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 July 24, 2007.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to maintain the hot water at 120*F or less. The water temperature was 133*F in the three bathrooms.
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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. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The facility failed to ensure that all bathroom exhaust fans were operational. The exhaust fan was not operational in one of two client bathrooms.
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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)(2) 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:
(2) A financial statement of income and expenses.
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Observations
The facility failed to ensure the annual report for 2006 included a financial statement of income and expenses.
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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 facility failed to provide evidence of an annual fiscal audit for the fiscal year ending June 30, 2006.
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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
In six of six client records reviewed (#1, 2, 3, 4, 5, 6), clients had signed a consent to release information for the Department of Corrections or another Minsec facility that did not contain what specific information was to be released or the purpose of the consent to release, therefore, rendering the consent invalid since it was not 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. |
709.93(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.
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Observations
The facility failed to develop individualized case consultations based on the specific client needs. In two of four client records reviewed, the case consultations in client record #2 were identical to those in the record of client #4. In addition, the summary and dispositions were identical from review to review for both record #2 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. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
The facility failed to document follow-up contacts. In six of six client records reviewed, #6, 7, 8, 9, 10 and 11, follow-up contact had not been done according to program policy and procedure.
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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. |