INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2006 through March 23, 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 April 27, 2006.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
The policies and procedures for the staff development plan does not include the timeframes for the completion of the needs assessment, the overall training plan, the training feedback, and the annual evaluation of the training plan.
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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 |
705.28 (b) (3) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Documentation for two fire drills, conducted on 4/25/05 and 6/16/05, revealed that the smoke detectors were not functioning properly. The corresponding notes and documents indicate that the repairs were not made within the 48 hour period.
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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 |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The treatment plan updates did not include a review of progress on previously stated goals.
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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 |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The follow-up policy did not address clients who do not successfully complete treatment.
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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 |