INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18 through 19, 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 November 21, 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
The facility lacked sufficient CPR/first aid coverage to cover all hours of operation from August 27, 2006 through October 16, 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. |
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
The facility is using a "Medical Release" form which constitutes a general consent to release information. The form fails to indicate who the information will be released to in eight of eight client records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
Consent to treatment forms contained a general consent to release in four of eight client records reviewed, #2, 4, 6, and 8.
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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)(2) 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:
(2) Specific information disclosed.
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Observations
Consent to release information forms did not identify the specific information to be disclosed in seven of eight records reviewed, # 1, 2, 3, 4, 5, 6 and 8.
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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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations failed to provide a composite picture of the client in five of eight client records reviewed, # 1, 2, 3, 4 and 5. Evaluations did not identify and evaluate the client's preferred coping mechanisms in six of eight client records reviewed, #2, 3, 4, 6, 7 and 8. the client's support systems were not evaluated in three of eight client records reviewed, #2, 4 and 7.
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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. |
709.52(a)(3) LICENSURE Support service type
709.52. 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
Proposed support systems were not identified in four of eight client records reviewed, #2, 3, 4, and 7.
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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. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Client #1 was admitted to the facility on August 2, 2006. The facility made contact with the Department of Corrections to obtain information on the client's medications, dosage and frequencies; however the facility had not received the information until September 11, 2006. After receiving the information on September 11, 2006, the facility failed to assist the client with obtaining the medication until September 22, 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. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
The record of services was incomplete in three of eight client records reviewed, #2, 6 and 8.
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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. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Progress notes were missing and/or had group progress notes that did not provide any opinion from the counselor regarding the client's participation and/or progress in five of eight client records reviewed, #2, 4, 6, 7 and 8.
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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. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
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Observations
Follow up information was incomplete in two of three client records reviewed, # 6 and 8.
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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. |