INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Recovery Resources A Service of 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 4, 2008.
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Plan of Correction
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of administrative policy and procedures on September 23, 2008, the facility failed to formulate a complete policy regarding the annual goals and objectives.
Findings:
The policy did not document time frames for the listed goals and objectives.
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Plan of Correction
The facility director will revise the facility goals and objectives to more clearly identify time frames for completion and review. They will be resubmitted to the Board President for review and signature by 10/17/08.
The Director will review and ensure that there are establish time frames for goals and objectives annually to make sure this does not recur.
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of eight client records on September 23, 2008, the facility failed to document clients were informed of the right to appeal a decision limiting access to his records to the project director in 8 of 8 records where required.
Findings:
The facility did not document that the clients were informed of this right in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The patient handbook has been revised to include this information. Staff will begin utilizing the new handbook no later than 10/20/08. The patients will continue to sign off that they have received a copy of the handbook.
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709.30(6) LICENSURE Client Rights
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of eight client records on September 23, 2008, the facility failed to document clients were informed of the right to submit rebuttal data or memoranda to his own records in 8 of 8 records where required.
Findings:
The facility did not document that the clients were informed of this right in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The patient handbook has been revised to include this information. Staff will begin utilizing the new handbook no later than 10/20/08. The patients will continue to sign off that they have received a copy of the handbook.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of eight client records on September 23, 2008, the facility failed to document group progress notes that contained the data, assessment and plan, for every group treatment session, in three of eight client records where required.
Findings:
The facility did not document group progress notes for every group treatment session, as listed in the client record of service log in client records # 2, 3 and 5.
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Plan of Correction
Director of OP Services will meet with the counselors no later than 10/31/08 to inform them that a progress note needs to be completed on all patients in all the treatment groups they attend. The Director of OP Services will complete random chart audits( a minimum of 2 per counselor per month) on a monthly basis and include them in her monthly report, beginning with Novembers monthly report to confirm that this is being completed. |