INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 30, 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 January 2, 2007.
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A space heater was in an office during the inspection.
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Plan of Correction
The prohibition of space heaters will be emphasized through a memo to the site. The Project Director will conduct an inspection to assure compliance. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Documentation of fire extinguisher training was not documented for one of two employees, # 2.
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Plan of Correction
Project Director will conduct staff meeting and train all staff in use of fire extinguisher, review emergency procedures and assign tasks during an emergency. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 one of two employees, # 2.
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Plan of Correction
Project Director will conduct staff meeting and train all staff in use of fire extinguisher, review emergency procedures and assign tasks during an emergency. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. 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 did not include lengths and patterns of use in four of six client records, #1, 2 , 3 and 6.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories did not contain complete information in six of six records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations did not include an assessment of the client's assets/strengths, support systems, coping mechanism, clients attitude towards treatment and negative factors that may inhibit treatment in six of six records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Support services were not indicated on treatment plans in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Employees at the Hanover site will be provided written feedback of the BDAP licensing review.
Project Director will conduct staff meeting and emphasize the expectation of documenting these areas.
Clinical supervisor will emphasize in 1-1 supervisory session, the expectation of documenting these areas.
AHCS UR will check for documentation and report results to supervisor and clinician.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Employee number 2 received only 12 of the 25 hours of training for the previous training year.
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Plan of Correction
Although the staff member received the training as planned, licensing did not credit specific training as the attendance certificate did not list hours or a sign-in sheet was not available. A training plan meeting licensing requirements currently exists; documentation of future trainings will be obtained in a form that is compliant with licensing expectation. |