INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21-23, 2009 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 and a plan of correction is due on October 23, 2009.
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Plan of Correction
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of the client orientation materials, the facility failed to demonstrate efforts to inform clients of their right to submit rebuttal data or memoranda to their own record.
The findings include:
The client orientation paperwork was reviewed on September 22, 2009. The facility failed to inform the client regarding the client's right to submit rebuttal data or memoranda to their own record.
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Plan of Correction
The listing of Patient Rights has been transcribed from the department regulations and has been posted in patient accessible areas as of 10/6/09
The office secretary will be responsible to maintain this posting and replace it if it becomes illegible or is remove for any reason.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client records.
The findings include:
Fifteen client records were reviewed on September 21-23, 2009. One record was required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 8.
In client record # 8, the client was involuntarily terminated from the project on July 22, 2009. There was no documentation of written notification to the client.
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Plan of Correction
Patients will sign a case consultation form at the time of involuntary discharge that states the reason for the involuntary discharge and that they have the right to appeal the discharge. The patient signature confirms it has been reviewed. This form is signed off by the Director of Residential Services. If at the time of her signature there is no documentation that the patient reviewed the form, she will be responsible to ensure a copy of the discharge case consult is generated and mailed to the home address given upon admission. The form has been revised 10/8/09 and will be implemented by 10/12/09 |