INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, through February 1, 2007 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 March 6, 2007.
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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
The project failed to document feedback forms in staff development files # 1, 2 and 5.
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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(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Personnel record #'s 4 and 5 failed to document an individual staff performance evaluation annually.
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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(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Personnel record #'s 4 and 5 failed to document a written copy of the annual evaluation.
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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)(3) 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:
(3) Purpose of disclosure.
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Observations
In client record #'s 1 through 8 the project failed to obtain voluntary consents from the client for the disclosure of information that include the purpose of the disclosures.
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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)(8) 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:
(8) Case consultation notes.
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Observations
Client record # 2 failed to include a case consultation within 90 days of admission.
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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. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The project failed to define follow-up documentation policies regarding clients who fail to keep scheduled appointments.
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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. |