KHK Site Specific Deficiencies #3 through # 20
3. The program did not have personnel files that contained documentation
indicating that the employee had reviewed and agreed to abide by the federal
regulations on the Confidentiality of Alcohol and Drug Abuse Patient Records (Title
42, Code of Federal Regulations, Part 2), as required by OAC 3793:2-1-03
(P)(7).
4. The program did not have personnel files that contained documentation
indicating that the employee had received and agreed to abide by each of the
following: personnel policies and procedures, client abuse/neglect policy, client
rights policy and client grievance procedure, as required by OAC
3793:2-1-03(P)(
(a) through (d).
5. The program did not have policies/procedures stating that employees have
not pled guilty to/been convicted of and of the offenses listed in division
(4)(a) of ORC 109.572, as required by OAC 3793:2-1-039(R)(2).
6. The program's qualifications for AOD program director did not include five
years experience in AOD or related services, as required by OAC
3793:2-1-03(F)(1).
7. The program did not have personnel files that included documentation of
cultural sensitivity training, as required by OAC 3793:2-1-03(O)(2).
8. The program did not have personnel files that included documentation of
infection control training, as required by OAC 3793:2-1-03(Y)(1).
9. The program did not have personnel files for individual service providers
of crisis intervention services that contained documentation of training in
CPR, first aid and de-escalation techniques, as required by OAC
3793:2-1-08(L)(3).
10. The program did not have client records that contained signed/dated
acknowledgment of receipt of a written summary of federal laws/regs regarding the
confidentiality of client records as required by 42 CFR Part B, Paragraph 2.22,
as required by OAC 3793:2-1-06(F)(5)(c).
11. The program did not have client records that contained an assessment that
included current OTC use, sexual history, strengths and weaknesses, as
required by OAC 3793:2-1-06(K)(3)(c), (m), (o) and (p).
12. The program did not have client records that contained a valid diagnosis,
as required by OAC 3793:2-1-06(F)(6).
13. The program did not have client files that contained a diagnosis rendered
by an appropriately licensed service provider, as required by OAC
3793:2-1-06(I)
14. The program did not have client records that contained progress notes
that included the date the staff member wrote the progress note, as required by
OAC 3793:2-1-06(N)(6).
15. The program did not have client files that demonstrated a group ratio of
client to counselor of 12:1, as required by OAC 3793:2-1-08(O)(
.
16. The program did not have client files that contained a disclosure of
information form that included the amount of information to be disclosed, as
required by OAC 3793:2-1-06(G)(5). Please note that this deficiency was previously
cited during the last certification survey.
17. The program did not have client records that contained a termination
summary that was prepared within 30 days after treatment terminated, as required
by OAC 3793:2-1-06(P).
18. The program did not have client records that contained a termination
summary that included the diagnosis, degree of severity at admission and
discharge, level of care and the date the service provider signed the note, as required
by OAC 3793:2-1-06(P)(4), (5), (6) and (9). Please note that this deficiency
was previously cited during the last certification survey.
19. The program did not have client files that contained a standing
physicians order for urinalysis, as required by OAC 3793:2-1-08(R)(1)(b).
20. The program did not have client files that documented client receipt of
education regarding the exposure to and treatment of tuberculosis, hepatitis B
and C and HIV disease, as required by OAC 3793:2-1-05(G)(14).
Report Prepared January 21, 2005 by:
Mary E. Orin LSW, CCDCII, Certification Specialist
Barbara L Deitz OCPS 1, LICDC
