INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27, 2006 through November 28, 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 2, 2007.
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Consent to release information forms were missing in one of four records reviewed, #2.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Exit signs, that were to be illuminated, did not have lights at seven of the ten exits from the facility.
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Plan of Correction
Janitorial service notified of the need to replace light bulbs. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Documentation of fire extinguisher training was not documented for one of three employees, # 2.
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Plan of Correction
Project Director will conduct staff meeting and train all staff in use of fire extinguisher, review emergency procedures and assign tasks during an emergency.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Documentation of emergency training was not documented for two of three employees, # 2 and 3.
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Plan of Correction
Project Director will conduct staff meeting and train all staff in use of fire extinguisher, review emergency procedures and assign tasks during an emergency.
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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
Psychosocial evaluations did not include an assessment of the client's assets/strengths, support systems, coping mechanism and clients attitude towards treatment in two of two records reviewed, #1 and 4. Psychosocial evaluations were not completed in two of two records reviewed, #2 and 3.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Progress notes did not evaluate or assess the client's progress during treatment in two of four records reviewed, #1 and 3.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
One of two case consultations was not completed, #1.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Project Diretor will review with supervisor the expectation of documented consultation every 90 days.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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