INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 6, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Twin Lakes Center Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to have the fire extinguisher inspected annually by the local fire department or fire extinguisher company.
At the time of the physical plant inspection on October 6, 2016, the fire extinguisher expired on 9/30/2015.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Outpatient Supervisor contacted the fire extinguisher company and they came in to check the equipment and update the tag on 10/6/2016. The Outpatient Supervisor will monitor this monthly to ensure that they are compliant. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six of six outpatient client records reviewed during the licensing inspection on October 6, 2016.
Client record #1 - Client was admitted to outpatient treatment on July 14, 2016, and was discharged on October 4, 2016. An individual treatment and rehabilitation plan was completed on 8-4-2016, but did not document the type and frequency of services.
Client record #2 - Client was admitted to outpatient treatment on June 15, 2016, and was discharged on September 28, 2016. An individual treatment and rehabilitation plan was completed on 7-5-2016, but did not document the type and frequency of services.
Client record #3 - Client was admitted to outpatient treatment on July 21, 2016, and was discharged on September 28, 2016. An individual treatment and rehabilitation plan was completed on 8-11-2016, but did not document the type and frequency of services.
Client record #4 - Client was admitted to outpatient treatment on July 28, 2016. An individual treatment and rehabilitation plan was completed on 8-15-2016, but did not document the type and frequency of services.
Client record #5 - Client was admitted to outpatient treatment on August 1, 2016. An individual treatment and rehabilitation plan was completed on 8-4-2016, but did not document the type and frequency of services.
Client record #6 - Client was admitted to outpatient treatment on August 22, 2016. An individual treatment and rehabilitation plan was completed on 9-12-2016, but did not document the type and frequency of services.
The findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Assistant Director will have the EHR vendor push the type and frequency from the initial treatment plan to the master treatment plan and the counselor can make appropriate changes as needed. This was completed by 10/14/2016. The manager of each unit will monitor this throughout the year during paperwork signing to ensure compliance. |