INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 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 October 23, 2006.
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Plan of Correction
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
A fire alarm or smoke detector was not set off during each fire drill.
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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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were missing a composite picture in three of five records reviewed, #1, 4 and 5. Psychosocial evaluations were missing coping/defense mechanisms in four or five records reviewed, #1, 3, 4 and 5.
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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. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates did not include a review of progress on previously stated goals in five of five records reviewed, # 1, 2, 3, 4 and 5.
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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. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The treatment plans were missing work therapy goals in five of five records reviewed, #1, 2, 3, 4 and 5.
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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. |