INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 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 January 12, 2007.
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Plan of Correction
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
The fire drill log did not identify the exit route used during a fire drill.
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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. |
711.51(b)(3)(ii) LICENSURE D&A History
711.51. 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 client's perception of use did not identify how the client's addiction impacted on his/her social, physical, and mental state in four of five client records reviewed, # 1, 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. |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. 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 support systems in four of six client records reviewed, # 1, 4, 5 and 6. The psychosocial evaluations did not assess negative factors that may inhibit treatment in six of six client records reviewed, # 1, 2, 3, 4, 5 and 6.
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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. |
711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Treatment plan updates did not review the client's progress on the goals from the prior treatment plan in five of six client records reviewed, # 1, 3, 4, 5 and 6.
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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. |
711.53(a)(7) LICENSURE Follow-up Information
711.53. 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 contained 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 in two of five client records reviewed, # 8 and 10.
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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. |