INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 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 22, 2006.
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Plan of Correction
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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
Fire drills were not conducted monthly.
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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 |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project goals and objectives did not consistently include the available resources to be utilized in order to achieve the goals. Some of the timeframes for completion were outside of the 2005/2006 fiscal year.
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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 |
709.26(c)(2) LICENSURE Personnel Management
709.26. Personnel management.
(c) The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:
(2) Plans for addressing these needs.
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Observations
The overall agency training plan was missing for the 2005/2006 training year.
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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 |
709.26(c)(3) LICENSURE Personnel Management
709.26. Personnel management.
(c) The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:
(3) A mechanism to collect feedback on training completed.
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Observations
There were no feedback forms in four of four personnel files reviewed for the 2004/2005 training year.
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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 |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Psychosocial evaluations in two of four records, numbers 1 and 2, were not evaluative and did not include information regarding assets/strengths, support systems and coping mechanisms.
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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 |