INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2006 to June 23, 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 July 17, 2006.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility did not have a staff on duty with current CPR certification for the following dates and shifts:
June 10, 2006 - 3:00 p.m. to 11:30 p.m.
11:15 p.m. to 7:15 a.m.
June 3, 2006 - 11:15 p.m. to 7:15 a.m.
May 27, 2006 - 3:00 p.m. to 11:30 p.m.
11:00 p.m. to 7:15 a.m.
May 20, 2006 - 3:00 p.m. to 11:30 p.m.
11:15 p.m. to 7:15 a.m.
May 19, 2006 - 11:15 p.m. to 7:15 a.m.
May 13, 2006 - 3:00 p.m. to 11:30 p.m.
11:15 p.m. to 7:15 a.m.
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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. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A space heater was found in the basement storage area. Portable space heaters are prohibited.
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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. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The front door to the facility has a double key deadbolt in place, temporarily, while the magnetic lock is being repaired. Although temporary, double key deadbolts are not permitted on exit doorways.
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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. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Employee numbers 8 and 9 did not have the required fire extinguisher training. Instruction may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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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. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Employee numbers 8 and 9 did not have the required emergency training. This training, as with the fire extinguisher training, may be included in the employee orientation, but must occur no later than seven days from the date of employment.
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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. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
The medication administration forms, in the client records reviewed, were inconsistent in documenting the explanations as to why a client missed a dose of medication.
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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)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Follow up is not being documented as per agency policy un the closed clinical charts reviewed.
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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. |