INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2007 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 August 17, 2007.
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Plan of Correction
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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 project failed to provide CPR certification and first aid training to a sufficient number of staff, so that at least one person trained in these skills is onsite during the project's hours of operation. A review of the staff development training file for the sole proprietorship on July 19, 2007 failed to provide documentation of first aid training.
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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
The non-residential facility failed to conduct fire drills monthly during the period of September 2006 through June 2007.
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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 nonresidential facility failed to maintain a written fire drill record to include date, time of evacuation, exit routes, number of persons in the facility, problems encountered and whether the smoke detector was operative at the time of the drills for the period of September 2006 through June 2007. An interview and discussion with the project director on July 19, 2007 verified the lack of fire drill documentation.
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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. |
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
The project director failed to complete intake and admission medical histories in three of four client files reviewed on July 19, 2007. Documentation of a medical histories was missing from client record number 2 with an intake date of December 4, 2006, client record number 3 with an intake date of May 6, 2007 and client record number 4 with an intake date of December 16, 2006.
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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. |
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
The project director failed to complete an intake and admission psychosocial evaluation in three of four client files reviewed on July 19, 2007. The facility failed to include documentation of psychosocial evaluations in client record number 2 with an intake date of December 4, 2006, client record number 3 with an intake date of May 6, 2007 and client record number 4 with an intake date of December 16, 2006.
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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. |
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
The facility failed to include documentation of client follow-up in accordance with project policies in one of one discharged records, client record number 4, on July 19, 2007 . An interview with the project director on July 19, 2007, further verified the lack of client follow-up documentation.
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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. |