INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 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 5, 2007.
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Plan of Correction
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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
Documentation that a new employee received fire extinguisher training within the required time frame was not provided in one of one clinical record reviewed, #4.
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Plan of Correction
Within 60 days, the clinical coordinator shall develop a orientation sign off sheet for all new personnel to indicate they recieved fire extinguisher training with-in 7 days of date of hire. This orientation sign-off sheet will be placed in their personnel file. |
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
Documentation that a new employee received emergency training within the required time frame was not provided in one of one clinical record reviewed, #4.
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Plan of Correction
Within 60 days, Clincial Coordinator shall develop an orientation sign-off sheet which verifies new personnel has recieved emergency training within 7 days of hire. Orientation sheet shall be maintained in personnel file. |
709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
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Observations
A policy regarding retention of client records was not provided.
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Plan of Correction
Within 60 days, the project director shall incorporate a policy regarding the retention of client records to the existing Client Records policy. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Treatment plans contained the same goals and action steps in six of six clinical records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Within 60 days, the clinical coordinator shall meet with DA treatment staff to review treatment plan mandates, specifically individualized treatment plans. Clinical Coordinator shall continue to review charts to ensure proper documentation. |