INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on November 1, 2006.
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Plan of Correction
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705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The ceiling tiles in the hallway were stained.
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Plan of Correction
The Facility Director will work with the landlord to correct this deficiency. |
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 language "disclose to/obtain from" was included on consent to release information forms found in client records #1, 3, and 4. These forms were obtained to permit the release of information to the Greene County Clerk of Courts. The language "disclose to/obtain from" was documented in client records # 1, 3, 4,and 5 for releases to the Green County probation office. The language "disclose to/obtain from" was documented on consent to release information forms found in client record #4. Whether or not the client accepted or rejected a copy of the consent was not documented on the client liability form in client record #2. These issues contribute to make the consents to release information forms uninformed and fail to assure that the consents were voluntary.
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Plan of Correction
The Clinical Supervisor will provide training and supervision to all staff regarding the effective and proper completion of the Consent to Release Information forms. Clinical Supervsor will continue to monitor same. |