INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2006 through December 20, 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 .
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Plan of Correction
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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 were not conducted during different staffing shifts.
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Plan of Correction
The Facility Director has met with the Facilities Coordinator and revised the process and procedure for conducting fire drills as follows: 25% of monthly fire drill schedules will be conducted during evening hours between the 6:00pm to 9:00pm service hours with the remainder to be scheduled throughout the rest of the service day. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Medical histories were not documented in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
This omission in the client intake packet occurred in the printing process. The Facility Director has added the Medical History Form back into the packet effective 1/10/07 and has retrained support staff in the preparation process. The Clinical Supervisor will complete retraining of the clinical staff on review of packets for completeness by 1/31/07. The Clinical Supervisor will also review active client charts and direct the completion and entry of the Medical History Form by counseling staff for those charts missing this form by 2/28/07. |
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
Psychosocial evaluations contained historical information rather than the counselor's assessment of the client in three of six records reviewed, #2, 4 and 5.
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Plan of Correction
The Clinical Supervisor has reviewed these charts will retrain the counseling staff involved on the proper assessment of historical information/data in the psychosocial evaluation by 2/15/07. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow up information was not documented in one of three client records reviewed, #5.
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Plan of Correction
The Clinical Supervisor has reviewed the chart in question and will retrain the counselor involved and review the followup documentation process with all clinical staff by 2/15/07. |
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
One of four employee records reviewed, #4, did not have documentation of HIV/AIDS training.
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Plan of Correction
This employee was scheduled for HIV/AIDS training that was cancelled by the provider. The Clinical Supervisor has registered this employee for this training through the SCA. This employee's training will be completed by 3/31/07. |