INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13 through 14, 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 9, 2006.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
An individual training plan was not provided for employee #2.
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Plan of Correction
At initial employment and annually, at the beginning of each fiscal year, a Drug and Alcohol Staff Training Needs Survey will be provided to each employee in which the employee will indicate areas of need and/or training interested. Using the individual employees Staff Training Needs Survey, an individual training plan for each employee will be developed outlining the trainings that will be provided for the entire fiscal year. A separate section will be developed in the employee file that will track trainings attended. Project Director and Facility Director will ensure that upon initial employment and at the beginning of each fiscal year that an individual traning plan is developed for each employee. The CEO will ensure that the project director complies with this area. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Employee #4 received 5 of the 25 required training hours for the 2005 training year.
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Plan of Correction
Using the individual employees Staff Training Needs Survey, an individual training plan for each counselor will be developed outlining the trainings that will be provided for the entire fiscal year, which is consistent with the required training hours. If an employee is employed on a part-time basis and is employed elsewhere, the employee will be required to submit verification of trainings attended. Project Director and Facility Director will conduct frequent audits of employee files to ensure that the training hours are met for each employee. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Employee #3 did not receive the required 30 hours of training for the 2005 training year.
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Plan of Correction
Using the individual employees Staff Training Needs Survey, an individual training plan for each counselor assistant will be developed outlining the trainings that will be provided for the entire fiscal year which is consistent with the required training hours. If an employee is employed on a part-time basis and is employed elsewhere, the employee will be required to submit verification of trainings attended. Project Director and Facility Director will conduct frequent audits of employee files to ensure that the training hours are met for each employee. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
A soap dispenser was not provided in the second floor hall bathroom.
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Plan of Correction
A soap dispenser shall be made available in all bathrooms throughout the facility. During each shift support staff shall ensure that all bathrooms are properly equipped. |
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
A financial statement of expenses was not included in the annual report.
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Plan of Correction
The Governing Body will ensure that expenses continue to be included in their annual report as in previous years. Although, this appears to be a printing error, the Governing Body will ensure that the annual report is printed correctly.
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