INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7-8 , 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 September 6, 2006.
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Plan of Correction
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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
Three out of three staff members do not have current CPR certification.
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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 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
The two means of egress from the third floor are located within fifteen feet of each other. There must be two means of egress from each level and the exits must be more than fifteen feet apart.
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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 (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
There was no documentation of fire extinguisher training in the personnel file for employee #3. Training in the use of fire extinguisher must be obtained and documented within 7 days of the date of hire.
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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 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
There was no documentation of a fire drill for the month of March 2006.
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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 (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
Personnel record # 3 has no documentation of training for emergency procedures. This training must be obtained and documented within 7 days of the hire date.
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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. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
The annual report for the year ending December 2005 was not completed.
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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(c) 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:
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Observations
Releases of information forms do not provide for an informed consent. In client record numbers 6, 7, 8, 9 and 10, the purpose was not consistently documented. In addition, client record # 8 contained a release of information form that did not document the specific information to be disclosed.
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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
One out of one client record, (# 9), is missing a treatment plan update.
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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)(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
One out of one client record, (# 10), is missing an aftercare 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. |