INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19 to June 21, 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 July 13, 2006.
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Plan of Correction
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709.123(d)(2) LICENSURE Aftercare Policy
709.123. Treatment and rehabilitation.
(d) Client management services.
(2) The project shall develop a written client aftercare policy.
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Observations
The aftercare policy was incomplete. It did not include timeframes for goals, support service, and the re-entry process.
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Plan of Correction
The policy inadvertently excluded the items listed. Since the survey, the policy has been updated by the Administrative Assistant to include time frames for goals, support service and the re-entry process. Policy has been distributed to appropriate staff and staff educated. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate routes could not be determined during the review as they were not included on the fire drill logs. It should be documented when patients are moved to a safe location in lieu of exiting the building.
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Plan of Correction
A new form had been developed which included documentation on where patients were moved in the building during a fire drill. However, the new form was not being utilized. The Safety Officer began utilizing the form immediately after the survey. |
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
The aftercare policy was incomplete. It did not include timeframes for goals, support service, and the re-entry process.
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Plan of Correction
The policy inadvertently excluded the items listed. Since the survey, the policy has been updated by the Administrative Assistant to include time frames for goals, support service and the re-entry process. Policy has been distributed to appropriate staff and staff educated. |