INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19, 2006 through October 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 November 16, 2006.
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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 third shift did not have a sufficient number of personnel trained in first aid.
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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 # 3 earned only eight of the 25 required hours of training for the 2005 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. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Showers did not have slip-resistant surfaces.
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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. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The exhaust fan in the second floor bathroom for children was not operational.
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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. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
The medication administration records did not include reasons why clients did not receive their medications as prescribed.
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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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations did not include a composite picture in five of five client records reviewed, # 1, 2, 3, 4 and 6. Psychosocial evaluations did not provide an assessment of the client's assets/strengths and negative factors that may inhibit treatment in three of five client records reviewed, # 1, 3 and 4.
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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. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
The discharge summary form did not include a section for the reason for this treatment experience in two of three client records reviewed, # 4 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. |