INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22, 2007 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 November 16, 2007.
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Plan of Correction
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of the facility's policy and client records, the facility failed to document physical examinations as per policy in three of seven records reviewed, #15,16 and 17. The policy indicated that a physical examination was required within 30 days of admission. Physical examinations were not documented in three records.
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Plan of Correction
Twin Lakes Center will enact a policy change effective 11/12/07 in which OP clients will not be "required" to obtain a physical examination. It will be "recommended" that they follow up with their personal physician for a comprehensive medical examination within 30 days of admission.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information in two of three records reviewed, #17 and 18.
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Plan of Correction
The office secretary will be responsible to complete the follow-ups per policy. The Director of OP Services will review the policy with the secretary no later than 11/12/07 and orient the secretary to the procedure. The secretary will be required to keep an ongoing list of all discharged patients so that the Director of OP Services can do random comparisons of the lists to ensure all follow ups are being completed. The Director of OP Services will report on this to the PI Committee on a quarterly basis. |