INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 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 October 4, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
The assessment of staff training needs was not completed for the July 2006 through June 2007 training year.
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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(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 training plan was not completed for the July 2006 through June 2007 training year.
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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(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 training plan was not completed for the July 2005 through June 2006 training year .
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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 # 2 only earned 19 hours for the July 2005 through June 2006 training year.
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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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Fire drills have not been conducted since September 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. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Fire drills have not been conducted since September 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. |
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
Fire drills have not been conducted since September 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. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Fire drills have not been conducted since September 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. |
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
Fire drills have not been conducted since September 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. |
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
Psychosocial evaluations did not assess the client's assets/strengths and negative factors that may inhibit treatment. Evaluations did not include a composite picture of the client, the client's support systems and the client's attitude towards treatment in five of five client records reviewed, # 1, 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. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
The treatment plans did not include any action steps or other measurable criteria to indicate how the stated goals would be achieved in three of four client records reviewed, # 1, 3, 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. |
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Support services were missing in four of four client records reviewed, # 1, 2, 3, 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. |
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
An aftercare plan was missing in one of three client records reviewed, # 2. Additionally, the aftercare plans did not include a contact person or the reentry process in two of three client records reviewed, # 1 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. |
711.94(e) LICENSURE Follow-up Policy
711.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The follow-up policy does not include timeframe(s) for when follow-up contacts will be made, nor does it include the method/manner of the follow-up attempt.
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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. |