INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 2006 to April 18, 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 May 19, 2006.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Employee B does not have the required HIV/AIDS training.
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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(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
In all charts reviewed, the consents to release information do not indicate that the client was offered a copy. Compliance with this standard may be demonstrated by indicating on the consent whether the copy was accepted or refused, posting a policy statement or including it in the client's orientation packet, etc.
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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 |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Medical histories in client records #3, 4, and 5 were incomplete. The medical history was missing in client record 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 |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
The discharge summaries in client records #5, 6, 7, 8 and 9 did not thoroughly address the reasons for treatment, services offered, the client's response to treatment, and the client's status at discharge.
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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 |