INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27, 2006 to December 1, 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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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
One of seven staff members, staff number 1, did not have an individual training plan.
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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. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
The front doors to the facility have double-keyed dead bolts. These type of locks are not permitted. Exits must be unobstructed and operable at all times. The facility needs to consider a crash bar or a lock that can be opened manually from within the facility.
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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. |
705.28 (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
Although fire extinguisher training is included as part of new employee orientation, there was insufficient documentation to verify the training. Three of seven employees, staff numbers 4, 7, and 9, did not document that training was received.
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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. |
705.28 (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
Although emergency training is included as part of new employee orientation, there was insufficient documentation to verify the training. Three of seven employees, staff numbers 4, 7, and 9, did not document that training was received.
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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. |
709.22(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
The financial statement of income and expenses was not included in the annual report.
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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. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The fiscal audit for the year ending June 30, 2005 was completed July 6, 2006. Audits need to be completed within six months of the end of the project's fiscal year. This audit should have been completed by December 31, 2005.
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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. |
709.92(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 are being dated the date they are due (30 days from intake) rather than the date completed. Therefore, compliance with agency policy cannot be determined. Signatures should be dated the date of completion or review. Please refer to Licensing Alert 04-05 'Dating of signatures'.
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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. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Out of eleven client records reviewed, four (client records #1, 3, 4, and 7) did not include the type and frequency of treatment services in the plan, and two (client records 5 and 9) did not include the type of treatment services.
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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. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates are being dated the date they are due rather than the date completed. Therefore, compliance with the standard cannot be determined. Signatures should be dated the date of completion or review. Please refer to Licensing Alert 04-05 'Dating of signatures'.
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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. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
The client's in four of nine records reviewed were prescribed medications. Two of these four records (client record numbers 3 and 5) did not include the type and frequency of medications. All medications being taken by a client whether prescribed by the project's physician or the client's private physician should be recorded in the chart indicating the name of the drug, dosage, and frequency of use.
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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. |