INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30 - February 1, 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 March 6, 2007.
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Plan of Correction
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
There was no documentation that fire drills were conducted during sleeping hours at least once every six months. Two fire drills were conducted at 6:00 AM, but clients are awake at that time anyway.
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Plan of Correction
The Fire Drill Policy was revised on 2/22/07 to reflect the necessary changes. The new policies will be reviewed with all fire monitors and maintenance staff the week of 2/26/07. The Housing Director will be responsible for monthly review and compliance, effective immediately. |
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
There was no documentation in the fire drill log that alternate exits were used during fire drills. The only documentation indicated for exit routes used was "primary".
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Plan of Correction
Current policy requires periodic use of alternate exists. Policy has been revised to ensure alternating between exit routes for each drill conducted. The new policies will be reviewed with all fire monitors and maintenance staff the week of 2/26/07. The Housing Director will be responsible for monthly review and compliance, effective immediately. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
In 2 out of 6 client records reviewed, specifically #2 and 3, several consent to release information forms did not include the specific information to be disclosed.
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Plan of Correction
Several consent forms did not include the specific information to be disclosed. As of 2/19/07 Release of Information forms were updated and all staff were trained on State Regulations and completion of Release of Information forms. The Associate Director will review files two (2) times monthly to ensure accuracy. The Director will review monthly to ensure compliance, effective 2/19/07. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Several consent to release information forms in 2 out 6 client records reviewed, specifically #2 and 3 , did not include the purpose of the disclosure.
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Plan of Correction
Several consent forms did not include the purpose of the disclosure. As of 2/19/07 Release of Information forms were updated and all staff were trained on State Regulations and completion of Release of Information forms. The Associate Director will review files two (2) times monthly to ensure accuracy. The Director will review monthly to ensure compliance, effective 2/19/07. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
The medication administration records (MARs) in 4 out of 6 client records, specifically #1, 2, 3 and 4, did not consistently include documentation regarding a client's self-administration of medications. In addition, the records failed to indicate when clients missed or refused taking their medications.
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Plan of Correction
As of 2/19/07, all staff were retrained on this State Regulation and client self-administration of medications and proper documentation of clients missing or refusing medications. The LPN and Associate Director will check medication weekly to ensure regulations are followed and the documentation is accurate. Any staff not following protocol will be referred to the Director for further action, effective 2/19/07. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The treatment and rehabilitation plans in 4 out of 4 client records reviewed, specifically #1, 2, 3 and 4, did not establish that work done by the client at the project is an integral part of treatment. The treatment plan only indicated that the client will participate in daily chores.
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Plan of Correction
Training was conducted on 2/19/07 with Counselor's Aides on documentation in progress reports and life skills notes as to specific client's community chores and client's follow through with assigned Life Skills/Work Therapy. Counselors will continue to document in treatment plan updates, client's progress on daily Work Therapy. Associate Director to check files and notes two (2) times monthly and Director one (1) time monthly to ensure compliance, effective 2/19/07. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
The aftercare plan in 1 out of 1 client records reviewed did not include specific goals with timeframes, the re-entry process or a contact person.
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Plan of Correction
February 19, 2007, all clinicians were trained regarding the State Regulations and the changes made to the Aftercare Plans, including specific goals, timeframes and re-entry process or contact person. Director will review files and Aftercare Plans before discharge to ensure accuracy, effective 2/19/07. |