INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 9 - 10, 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 February 7, 2007.
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Written individual training plans for the 2006-2007 training year had not been documented in two of six employee records reviewed, #1 and 6.
The written individual training plan for employee #2 lacked the supervisor's signature and any comments to indicate that there was supervisory input in the development of the plan.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
The facility lacked sufficient CPR coverage for all hours of operation from October 24, 2006 through December 13, 2006.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
|
Observations
The handrail leading from the second floor exterior stairs to the street level does not extend to the bottom stair.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Fire extinguisher training was not completed for three employees within seven days of employment, as indicated in three of six personnel records reviewed, #3, 4, and 5.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Personnel training for assigned duties during emergencies was not completed for three employees within seven days of employment, as indicated in three of six personnel records reviewed, #3, 4, and 5.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Work performance evaluations were not conducted as per personnel policies and procedures and state regulations in five of six personnel records reviewed, #1, 3, 4, 5, and 6. Employees number 3, 4 and 5, lacked the 64 day and 127 day probationary evaluations in accordance with facility policy. Employee #1 has not had an annual evaluation since the one conducted in 2002. Employee #6 had no evaluation in the file.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
|
Observations
Criteria for admission did not indicate an age, nor did it provide a statement of geographic boundaries served.
|
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.
|
Observations
Psychosocial evaluations failed to identify client assets/strengths in three of five client records reviewed, #1, 3, and 5.
Psychosocial evaluations failed to identify support systems in two of five client records reviewed, #1 and 3.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |