INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on September 27, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Twin Lakes Center, Inc (Johnstown) 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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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility policy and procedures, the manuals were not organized and were repetitive.
The findings include:
Several policy manuals were reviewed on September 24 th and 25 th, 2012. The manuals included documentation that was outdated and contradictory. The manuals were missing information relative to other project facilities.
The board president and the project/facility director signed on 9-20-2012 that the manual had been reviewed and updated, however the manual was not updated.
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Plan of Correction
The Executive Director will ensure that all of the policy manuals will be moved to the computerized format and that they will all be updated and accurate prior to 12/31/12. |