INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 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 August 15, 2006.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
The overall plan for addressing training needs for the 2006 training year (January through December) was missing.
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Plan of Correction
The Project Director will create the training plan. It will be completed annually, and be presented to the managers annually. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
The annual evaluation of the overall plan was missing for the 2005 training year.
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Plan of Correction
An overall evaluation for the 2005 training plan was compiled by the Director Tom Whiteman, using the individual evaluations from each of the therapists. For 2006 Tom Whiteman will use the evaluations collected from each individual therapist to compile a summary of the overall evaluation of the training plan. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility had a heater that was not permanently mounted or installed. Portable space heaters are prohibited.
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Plan of Correction
The employee using the space heater was notified that it does not meet state regulations. It was immediately removed. The staff will bring extra sweaters for cooler periods in the office. The temperature of the suite will be agreed upon with the staff. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The use of alternate exit routes was not documented.
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Plan of Correction
The site managers will include on their fire drill logs the use of alternate exit routes when submitting them monthly to the Director. Logs will be submitted on the second Friday of every month. The Director will review to ensure that the use of alternate routes is being included in drill and documented. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
An alternate procedure has been approved by the Department, however, documentation that a smoke detector or fire alarm was inspected and operational was not provided as required.
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Plan of Correction
Effectively immediately, when Bonnie Heine submits the fire drill logs on the second Friday of every month they must include documentation paperwork from the fire alarm inspection company and when the fire alarm or smoke detector was tested for that month. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project goals and objectives did not identify any available resources.
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Plan of Correction
The goals and objectives will be created each year by the Project Director who will ensure that they will include the available resources or responsible personnel.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
A written agreement for 24-hour emergency psychiatric and medical coverage was missing.
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Plan of Correction
A revised referral agreement will be sent to Belmont hospital. It will include the 24 hour emergency psychiatric and medical coverage agreement. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The filing cabinets and storage room for clinical record storage were unlocked during the inspection.
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Plan of Correction
The administrative assistant will check the lock on the chart room several times per day to ensure that no one has left the room unlocked. If a staff person does not relock the door the manager will be notified. Repeat offenders will be fined. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Parent/guardian signature lines were included on the consent to release information forms. Parental consent for disclosure of information is not mandated by state law and cannot be required.
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Plan of Correction
A new release form with parent signature removed was created. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations did not assess the client's assets/strengths, support systems, coping mechanisms, and negative factors that may inhibit treatment in five of five client records, # 1, 2, 3, 4 and 5.
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Plan of Correction
Each site manager will have a staff training by September 30, 2006 which will address the following objective:
Creating an accurate psychosocial which includes strengths, weaknesses, support systems, coping mechanisms and risk assessment.
Staff will submit to the manager 3 psychosocial evaluations for review by October 15, 2006. The manager will continue to review charts on monthly basis and give individual feedback to each therapist. |
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 did not include a review of the client's progress on previously stated goals in four of four client records, # 1, 2, 4 and 5.
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Plan of Correction
Each site manager will have a staff training by September 15, 2006 which will address the following objectives:
Creating a treatment plan which has a review of client's measurable goals, and action steps from previous treatment plans.
Each staff person will submit 3 charts for review by October 1, 2006. The manager will review to verify completion of treatment plan updates as well as for content of update. Content should include a review of client's goals and action steps from the treatment plan
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