INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28 through 30, 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 September 25, 2006.
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Plan of Correction
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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
Emergency training was not provided within the required time frame for two employees, #1 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. |
709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Documentation of the governing body approval of the plan for the coordination of client treatment and rehabilitation services was not provided.
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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. |
709.26(a) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
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Observations
Documentation of the governing body approval of project personnel policies and procedures was not provided.
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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. |
709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Documentation of the governing body approval of the policy to implement and coordinate personnel management was not provided.
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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. |