INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17 through 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 May 19, 2006.
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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
Individual training plans were not timely in records # 2, 3, 4 and 5.
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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 |
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 sufficient CPR coverage for operational hours.
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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 |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Employee #3 and #5 did not have the required training hours.
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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)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol history did not include lengths and patterns of use in all records reviewed. The prior treatment history did not include where, when and the outcome 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(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Aftercare plans were missing in records #11 and #12.
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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(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Follow-up information was not documented as per agency policy 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 |