INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 13-14, 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 April 12, 2007.
|
Plan of Correction
|
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.
|
Observations
Staff did not utilize the mechanism according to program policy to provide feedback for the training attended.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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.
|
Observations
Employee #49 was missing documentation of having received the department approved mandatory communicable disease training hours.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Fire drills were not documented for February 2007 or December 2006.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
The forms used in the documentation of fire drills throughout 2006 did not address all areas required by this regulation.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
|
Observations
Follow up was not documented for all discharges in records reviewed in accordance with agency policy. Documentation of follow up in client record # 10 demonstrates that the follow up was not done within the appropriate timeframe.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
The manual at the main administrative office and the manuals at the various locations reviewed were not consistent with regard to policies and procedures. The general organization of the manual made the review difficult and increased the potential for misunderstanding the intent of various procedures.
|
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:
|
Observations
The HIPAA Notice of Privacy Practices form has errors in sections III L. and O.; IV. F; V. A and C.; VI E and H and VII. The "Authority to Represent" form used for Medical Assistance is a general consent to release information. General consents to release information do not meet the requirements of applicable confidentiality laws.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
|
Observations
Physician signatures were not consistently dated throughout the year being reviewed. Consequently it could not be determined that this requirement was being consistently met.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(6) 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:
(6) Inventories.
|
Observations
Documentation did not support that all prescription stock medications were being inventoried. Inventories are not required for over the counter medicines but all prescription stock medications must be inventoried in accordance with this regulation.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Psychosocial evaluations in client records # 2, 3, 5, 6 and 7 were either incomplete or illegible. Evaluations must address all of the areas required by the standard and interpretive guideline.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |