This report is a result of an on-site licensure renewal inspection conducted on November 29, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Two Roads Counseling Services, 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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Observations
The facility failed to document an individual treatment plan that included the type and frequency of treatment and rehabilitation services in three of four client records reviewed on November 29, 2018.
Client # 1 was admitted September 6, 2018. The treatment plan was completed on October 25, 2018.
Client # 2 was admitted April 23, 2018 and discharged October 26, 2018. The treatment plan was completed on May 16, 2018.
Client # 3 was admitted April 19, 2018. The treatment plan was completed on May 10, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The administrative assistant has updated the treatment plan form to include the type and frequency of treatment services. The project/facility director has revised the treatment plans for clients # 1, 2, 3 to include the type and frequency. The project/facility director will conduct random chart audits to ensure the treatment plan documentation is completed.
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