INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10 through 11, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on May 19, 2006.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Employee #6 did not have the required HIV/AIDS training.
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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 |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Defense mechanisms were missing in all records. Support systems were not evaluated in records #1 and 2.
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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 |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates did not assess the client's progress as it relates to the stated goals on the previous treatment plan in all records 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 |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
The copy to client section was left blank in records #1 and #4.
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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 |