INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 24 through 26, 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 May 19, 2006.
|
Plan of Correction
|
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 #7 did not have required HIV/AIDS and TB/STD training.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
The female client's lavatory on the first floor has an exhaust fan that is not operable.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
The lengths and patterns of use were not documented from first use through last use in a majority of records. The prior treatment history did not contain when this occurred and the outcomes of those treatment experiences in records #5, 6, 7, 8, 9, 20, 21 and 22.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Evaluations did not address coping/defense mechanisms and negative/barriers toward treatment in a majority of records.
|
Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |