INITIAL COMMENTS
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This is an on site licensure renewal inspection conducted on April 25-27,2006 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 29,2006.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
The project director must be selected in accordance with this regulation and the Licensing Alert issued in May 2005. The person currently designated as the Project Director does not fulfill all of the responsibilities required for a project director as defined in the Licensing Alert.
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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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The fire drill log did not contain all of the required information. The exit routes used were not addressed in the documentation presented. The written fire drill record must include the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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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
No determination could be made as to whether alternate exits were used since this component of documentation was missing from the fire drill documentation presented. Documentation must demonstrate that various fire exits available are utilized during the fire drills over the course of the 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 |
711.81(b)(3)(i) LICENSURE Medical History
711.81. 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 incomplete in files # 3, 4 and 8. Histories need to be constructed to collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated. A history documenting the client's personal medical history, family medical history, and history of illness and symptoms is required.
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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 |
711.81(b)(3)(iii) LICENSURE Personal History
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories were incomplete in records # 3, 4, 7, and 8. Histories must be collected with as much information as possible. Personal histories should include historical and current personal data such as: family, legal, employment/vocational, educational, military, recreational, sexual, and others where appropriate.
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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 |
711.81(b)(6) LICENSURE Psychosocial Evaluation
711.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not address all required components in files # 2, 3, 7 and 8. The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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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 |
711.84(e) ELEMENT Follow-up Policy
711.84. Project management services.
(e) The project shall develop a written follow-up policy.
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Observations
The agency policy does not address the issue of follow up with clients who are unsuccessfully discharged. The intent of this regulation is that follow up be completed for all discharges ( in addition see the interpretive guideline for follow up information -711.83(a)(7). The policy must address follow up procedures for both successful and unsuccessful discharges.
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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)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories were incomplete in records # 1, 2, 3, and 8. Histories must be collected with as much information as possible. Personal histories should include historical and current personal data such as: family, legal, employment/vocational, educational, military, recreational, sexual, and others where appropriate.
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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 address all required components in files # 1, 2, 5 and 6. The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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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 agency policy does not address the issue of follow up with clients who are unsuccessfully discharged. The intent of this regulation is that follow up be completed for all discharges (in addition see the interpretive guideline for follow up information -711.93(a)(7)). The policy must address follow up procedures for both successful and unsuccessful discharges.
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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 |