INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25 and 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 November 20, 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 a staff member with CPR certification on duty during the following hours on the following dates: 3:30 PM - 11:00 PM October 14, 2006, 5:00 PM - 11:00 PM October 4, 10 and 16, 2006, 9:00 PM - 11:00 PM October 1, 3, 11, 15 18, 19 and 25, 2006 and 9:30 PM - 11:00 PM October 17, 2006.
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Plan of Correction
Said staff was immmediately scheduled and completed CPR training as required. Recertification needs will be monitored by the Department Supervisors and the Program Director. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
The facility's census on the dates listed below exceeded 7 clients, however, the facility had only one primary care staff person on duty for the following shifts and dates: 11:30-7:30 PM on August 24, 25, 26, 27, 28, 29, 30, September 6, 12, 13, 14, 15, 16, 24 and October 5, 6, 7, 8, 9, 13, 20 and 21.
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Plan of Correction
Program Director and Nurse Manager will immediately begin monitoring census to ensure that additional primary care staff are scheduled when required to comply with client/staff ratios on all shifts. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility's temperature logs for the freezers indicated temperatures greater than 0 degrees Fahrenheit on all but three days from October 1 through 25, 2006.
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Plan of Correction
The Program Director will submit a work order to the Regional Facilities Plant Manager requesting that the freezer thermostats be analyzed to determine if they are functioning properly. The Program Director and Cook will assess the appropriateness of times at which temperature readings are taken. A repeat temperature will be taken one hour after any temperature reading exceeds 0 degrees Fahrenheit.
Addendum: New thermometers were purchased immediately and placed in each freezer. Staff were promptly advised of the new procedures including repeat monitoring each hour if any temp is out of range and to notify supervisor. |
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 five of twelve client records reviewed, #2, 3, 6, 10 and 12.
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Plan of Correction
The Program Director will contact the Continuous Program Improvement Director to obtain an agency approved medical release form which meets licensing standard and train staff on its implementation.
Addendum: Use of the Medical Release form has been terminated effective immediately. Staff were advised of such and all blank copies of the form were removed and destroyed. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates did not include a review of progress on previously stated goals in seven of seven client records reviewed, # 1, 2, 3, 6, 9, 10 and 12.
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Plan of Correction
The Program Director and Program Supervisor will train clinical staff to write a comment specific to the progress on previously stated goals on each treatment plan update. |