INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23 through 24, 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 November 21, 2006.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The individual assessment of staff training needs was not completed as per agency policy.
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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. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A space heater was in an office in the basement of the building.
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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. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Two exits in the basement of the building were obstructed by children's toys.
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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. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Documentation that staff received fire extinguisher training within the required timeframe was not provided in five of five personnel records reviewed, # 3, 4, 5, 6 and 7.
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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. |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Cleaning supplies in the daycare are stored in an unsecured cabinet. Cleaning supplies are unsecured and accessible to children in many of the family bathrooms.
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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. |
709.28(c)(5) 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:
(5) Dated signature of witness.
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Observations
The consent to release information form did not contain a space for the date of the witness signature.
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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. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Physical examinations were not documented in four of eleven clinical records reviewed, # 1, 3, 5 and 11.
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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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluations were incomplete. Specifically, the composite picture was missing in three of six clinical records reviewed, # 1, 2 and 4. Support systems were not evaluated in four of six clinical records reviewed, # 1, 2, 4 and 6. Coping mechanisms were missing in five of six clinical records reviewed, # 1, 2, 4, 5 and 6.
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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. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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
The disposition of the case consultation was missing in four of six clinical records reviewed, # 1, 3, 5 and 6.
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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. |