INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2006 through June 28, 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 July 24, 2006.
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Plan of Correction
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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.
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Observations
Training feedback was not completed for all external training attended.
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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
The fire drill logs indicate that during a drill all personnel and clients congregate on the fifth floor landing in either of the two stairwells and that they do not fully exit the building during a fire drill.
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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(a)(1) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(1) Recruitment, selection, promotion and termination of staff.
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Observations
The policies and procedures for the recruitment and selection of staff did not indicate how job openings will be made known to potential candidates or who would interview and select candidates.
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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. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
The current record keeping system is inefficient for the retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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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. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation did not evaluate the following areas: strengths/assets, support systems, and negative factors that may inhibit treatment in seven of ten clinical records reviewed, # 1, 2, 4, 5, 7, 8, and 9.
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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
The treatment plan updates did not include a review of progress on goals of the previous treatment plan in four of nine clinical records, # 2, 3, 7, and 9. Treatment plan updates were missing in two of nine clinical records, # 5 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. |
709.93(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
The aftercare plan did not contain individualized goals or time frames for each goals in one of two clinical records, # 11. One of two clinical records was missing an aftercare plan, # 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. |