INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2007 through January 9, 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 2, 2007.
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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 training needs assessment forms were not complete as per facility policy in three of six personnel records reviewed, # 1, 5 and 6.
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Plan of Correction
Corrections were made immediately. Individual training plans now include potential providers and projected time frame for completion. Deficiency was the responsibility of the Director. The director will personally examine all files on random basis to ensure completion. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
There were no thermometers in the freezers or refrigerators in any of the client apartments during the inspection.
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Plan of Correction
Corrections were made immediately. ACA will keep thermometers in all refrigerators. Deficiency was the responsibility of the Director. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential 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.
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Observations
The rear external concrete steps leading to the parking lot of the facility did not have a handrail installed.
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Plan of Correction
Correction will be made within 30 days. A handrail will be constructed. Deficiency was the responsibility of the Director. |
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 of fire extinguisher training was not provided for two new employees, # 3 and 6.
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Plan of Correction
Corrections were made immediately. All new employees will be trained and documentation will occur within 7 days of hire. Deficiency was the responsibility of the Director. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 new employees, #3 and 6.
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Plan of Correction
Corrections were made immediately. All new employees will be trained and documentation will occur within 7 days of hire. Deficiency was the responsibility of the Director. |
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 did not include an assessment of the client's problems/needs, assets/strengths, support systems and negative factors that may inhibit treatment in three of six client records reviewed, # 2, 3 and 5.
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Plan of Correction
Corrections were made immediately. Psychosocials were condensed to become more effective and include pertinent information. Deficiency was the responsibility of the Director.The Director will personally examine all files on random basis to ensure completion. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The treatment plan updates did not include a review of the client's progress related to previously stated goals in five of six client records reviewed, # 1, 2, 4, 5 and 7.
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Plan of Correction
Corrections were made immediately. All clinicians were trained in appropriate completion of treatment plans. Deficiency was the responsibility of the Director. The director will personally examine all files on random basis to ensure completion. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The type and frequency of treatment services prescribed by the initial treatment plan were not provided in three of six client records reviewed, # 1, 2 and 7.
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Plan of Correction
Corrections were made immediately. Initial treatment plans were changed to reflect individual services provided. Deficiency was the responsibility of the Director. The director will personally examine files or random basis to ensure completion. |