INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2006 and November 15, 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 December 12, 2006.
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Plan of Correction
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709.28(c)(4) 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:
(4) Dated signature of client or guardian.
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Observations
Information was released without client consent in one of five records reviewed, #2.
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Plan of Correction
The clinical director will review confidentiality laws with clinical staff by Dec. 30, 2006. The quality assurance technician will perform monthly chart reviews on 20% of all active client charts to insure there are signed releases for all parties to whom information is released. |
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
Fire extinguisher training was not documented within the required time frame in four of six personnel records reviewed, # 3, 4, 5 and 6.
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Plan of Correction
The project director will ensure that supervisors follow all orientation guidelines when orienting new staff. This orientation will include safety training regarding the location and use of fire extinguishers within the first 7 days of hire. |
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
Emergency training was not documented within the required time frame in four of six personnel records reviewed, # 3, 4, 5 and 6.
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Plan of Correction
The project director will ensure that all supervisors sign documentation of safety training for new staff within 7 days of hire and that this information is placed in the employee file. |
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 as per agency policy. Employee input was not documented in three of six personnel records reviewed, #3, 4 and 6.
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Plan of Correction
The project director will ensure all supervisors have completed staff training needs assessments with their supervisees and that this documentation is placed in the employee files. The project director will also create a checklist of tasks to be completed at annual employee reveiws. |