INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2007 and March 21, 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 April 16, 2007.
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Plan of Correction
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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 non-residential facility failed to maintain a written fire drill record that included whether the fire alarm or smoke detector was operative and the amount of time it took for drill evacuation.
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Plan of Correction
P P279: The fire drill log maintained by Aldie indicated the overall time it took to complete the drill instead of the time it took to evacuate the building. The facility director, who is responsible for conducting the fire drills, has corrected the written log to indicate the amount of time it takes to evacuate the facility. The facility director shall insure that the fire drill log is completed properly after each drill.
Aldie is not able to operate (i.e., set off) the fire alarm during drills because the fire detection and alarm system is tied into all the other tenants in the building were the facility is located. Instead, the test button will be activated on a smoke detector that is not tied into the fire alarm system when conducting fire drills at this facility. The facility director shall document the use of this alternative device in the written fire drill record. Aldie's executive director shall submit a request by April 30, 2007, to the Department of Health for an exception to the regulation requiring operation of the fire alarm system during drills.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The nonresidential facility failed to set off the fire alarm or smoke detector during each fire drill.
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Plan of Correction
P P285: Aldie is not able to set off the fire alarm during drills because the fire detection and alarm system is tied into all the other tenants in the building were the facility is located. Instead, the test button will be activated on a smoke detector that is not tied into the fire alarm system when conducting fire drills at this facility. The facility director shall document the use of this alternative device in the written fire drill record. Aldie's executive director shall submit a request by April 30, 2007, to the Department of Health for an exception to the regulation requiring operation of the fire alarm system during drills. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The governing body failed to make available to the public an annual report.
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Plan of Correction
L 0135: Aldie placed a notice in the appropriate newspaper announcing the availability of Aldie's annual report eight months after the end of the 2005/2006 fiscal year, instead of within the required six month period. The administrative assistant shall send future notices to the appropriate newspaper within the required time period, and the executive director shall be responsible for insuring that notices regarding the availability of Aldie's annual report are published within six month of the end of the fiscal year. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The governing body failed to make provisions through written agreement with a licensed hospital or physician for 24-hour medical coverage.
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Plan of Correction
L 0167: Aldie has utilized the same physician for several years to provide 24-hour medical coverage. However, when it was time to renew this agreement, Aldie inadvertently sent the wrong agreement form to the physician. This error has been corrected, and Aldie now has the appropriate written agreement on file documenting 24-hour medical coverage. The administrative assistant shall send the physician the proper agreement form at the time of future renewals, and the quality assurance coordinator shall review this and the other written agreement forms for compliance with relevant regulations. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The project director failed to secure client records located in the kitchen in locked storage containers. The client record file cabinet located in the kitchen does not have a lock.
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Plan of Correction
L 0275: Some client records for persons who were scheduled to be seen by a staff member that day were temporarily stored in closed, but not locking, filing cabinets in the staff kitchen. Locks are in the process of being added to those filing cabinets that will hold client records. The office manager shall be responsible for insuring that all client records are secured within locking storage containers. |