INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on September 28, 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.( Bedford) 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an onsite physical plant inspection on September 28, 2012, the facility failed to ensure all exits were unobstructed.
The findings include:
The project is located on the second floor of the building and includes other programs. The business across the hall from the facility had blocked the second exit with a wire rack holding pamphlets.
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Plan of Correction
On 10/4/12, the outpatient supervisor had the wire rack with pamphlets removed. The neighboring office is aware that they will not be able to place anything at that location due to the fire hazard it presents. The outpatient supervisor will monitor the hallway weekly to ensure that it does not reoccur. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a client record review, the facility failed to complete psychosocial evaluations as stated in agency policy in five of five client records.
The findings include:
Five client records were reviewed on September 28, 2012. Five of the five client records were required to have a psychosocial evaluation completed within thirty days of admission, as per agency policy. The psychosocial evaluations were completed on line on the Star program. The information provided was not comprehensive of the information required for the psychosocial evaluations.
Client #1 was admitted to outpatient treatment on July 30, 2012. A psychosocial evaluation was due to be completed by July 30, 2012. Documentation of a psychosocial evaluation was not completed for client #1.
Client #2 was admitted to outpatient treatment on August 16, 2012. A psychosocial evaluation was due to be completed by august 16, 2012. Documentation of a psychosocial evaluation was not completed for client #2.
Client #3 was admitted to outpatient treatment on August 1, 2012. A psychosocial evaluation was due to be completed by August 1, 2012. Documentation of a psychosocial evaluation was not completed for client #3.
Client #4 was admitted to outpatient treatment on August 13, 2012. A psychosocial evaluation was due to be completed by August 13, 2012. Documentation of a psychosocial evaluation was not completed for client #4.
Client #5 was admitted to outpatient treatment on July 25, 2012. A psychosocial evaluation was due to be completed by July 25, 2012.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
On 10/8/12, satff were made aware that Twin Lakes Center was no longer completing the psychosocial forms on the STAR system. On 10/8/12, the Director of Outpatient Services and the Director of Residential Services informed staff that Twin Lakes Center was going back to our previous psychosocial assessment that we had used successfully in the past. The outpatient supervisor and the residential supervisor will ensure that all staff are compliant with this change and that the psychosocial assessments are completed by the due date. |