INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on July 9 through 13, 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 August 6, 2007.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to provide documentation of feedback for training attended outside the facility.
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Plan of Correction
Facility Director will provide a feedback questionnaire/evaluation form to all staff attending off campus trainings. All staff members attending an off campus training will be required to submit the feedback questionnaire/evaluation form to Facility Director within 24 hours of the off campus trainings completion. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to provide a sufficient number of staff trained in first aid and certified in CPR. Seven staff schedules were presented for the months of June and July and no one on duty during these months was certified in CPR or trained in first aid.
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Plan of Correction
Facility Director will provide an up-to-date list of CPR/First Aid Qualified staff to the Front Desk Coordinator, who is responsible for duty shift staff scheduling.
Front Desk Coordinator will ensure that at least one CPR/First Aid Qualified staff is scheduled for every working shift. |
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
The facility had only one fire drill documented during sleeping hours in the past year.
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Plan of Correction
Student Services Director will instruct Fire Marshall and Assistant Fire Marshall to perform one fire drill during sleeping hours every six months.
Student Services Director will inspect Fire Drill Logbook every six months to ensure a fire drill is completed during sleeping hours. |
709.32(c)(2) 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:
(2) Drug storage areas.
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Observations
The facility had external and internal medications stored on the same shelves within the drug storage area.
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Plan of Correction
Student Services Director will have Health Office Staff reorganize medication cabinet, so that internal medications are not mixed with external medications.
Student Services Director will perform random inspections of medication cabinet to guarantee internal and external medications remain separated. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Drug and alcohol histories were missing the lengths and patterns of use in three of ten client records reviewed, #1, 2 and 9. The clients's prior treatment history was missing in one record reviewed, #3. The drug and alcohol history received from another facility was not reviewed with the client in one record reviewed, #7.
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Plan of Correction
Student Services Director will have Counseling/Clinical Supervisor review the appropriate documentation of the Drug/Alcohol History section of the Psychosocial document in a training session by 08-20-07. Subsequent trainings, scheduled monthly, will review all aspects of client record documentation.
Student Services Director will have Counseling/Clinical Supervisor ensure that proper client record documentation is being completed. This will happen through Counseling/Clinical Supervisor performing ongoing peer reviews by randomly selecting one client file from each counseling staff member's caseload monthly. |