INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 18, 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 January 12, 2007.
|
Plan of Correction
|
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
The program did not provide documentation that alternate exits were used during fire drills.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Psychosocial evaluations did not include assets/strengths in five of six records reviewed, #1, 2, 3, 5 and 6. The evaluations did not include support systems in four of six records reviewed, #1, 3, 5 and 6. Evaluations did not address coping/defense mechanisms in four of six records reviewed, #1, 2, 4 and 5. The evaluations did not include negative factors that may inhibit treatment in three of six records reviewed, #1, 2 and 4.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
|
Observations
Treatment plan updates did not include a review of progress on previously stated goals in four of six records reviewed, #2, 3, 4 and 5.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |