INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2008 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 20, 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 18, 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. |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
Based on the review of three personnel records, the facility failed to document that the employee was informed of the right to inspect his own records in one of three personnel records where required.
Findings:
There was no documentation that the employee was informed of this right in personnel record #3.
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Plan of Correction
Each new employee will be required to sign off that they have reviewed the Employee Handbook, and submit this form to the Business Manager within 5 working days of having reviewed the handbook. The Business Manager will forward the form to the department supervisor. This department supervisor will confim that the form has been signed when they complete the staff's 90 day evaluation. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on the review of three personnel records, the facility failed to document that the employee was informed of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their record in one of three personnel records where required.
Findings:
There was no documentation that the employee was informed of this right in personnel record #3.
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Plan of Correction
Each new employee will be required to sign off that they have reviewed the Employee Handbook, and submit this form to the Business Manager within 5 working days of having reviewed the handbook. The Business Manager will forward the form to the department supervisor. This department supervisor will confirm that the form has been signed when they complete the staff's 90 day evaluation. |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of three personnel records on September 18, 2008, the facility failed to document that the employee was informed of the right to submit rebuttal data or memoranda to his own records in one of three personnel records where required.
Findings:
There was no documentation that the employee was informed of this right in personnel record #3.
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Plan of Correction
Each new employee will be required to sign off that they have reviewed the Employee Handbook, and submit this form to the Business Manager within 5 working days of having reviewed the handbook. The Business Manager will forward the form to the department supervisor. This department supervisor will confirm that the form has been signed when they complete the staff's 90 day evaluation. |
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 six client records on September 18, 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 6 of 6 client 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 and 6.
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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 10/17/08. The patients will continue to sign off that they have received a copy of the handbook. |
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 six client records on September 18, 2008, the facility failed to document clients were informed of the right to submit rebuttal data or memoranda to his own records in 6 of 6 client 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 and 6.
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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 10/17/08. The patients will continue to sign off that they have received a copy of the handbook. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of six client records on September 18, 2008, the facility failed to document an individual treatment and rehabilitation plan in three of six client records where required.
Findings:
The facility did not document that an individual treatment and rehabilitation plan was developed in client records # 1, 3 and 4.
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Plan of Correction
The Director of OP services will utilize secretarial staff in OP offices to assist with monitoring paperwork completion checklists to ensure that treatment plans are being completed within the time frames and they will alert her if things are not being completed as required.This will be in place by 10/21/08 |