INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2017 by staff from the Division of Drug and Alcohol Program Licensure. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to provide documentation of TB/STD training in one of one personnel record. The TB/STD training documentation was due by 3-1-2017. TB/STD training documentation was not available at the time of the November 16, 2017 annual inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The required documents for TB/STD trainings have been obtained. This certificate was completed on 8/24/04. A copy of tis certificate will be provided upon request. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to complete an annual report for the year ending July 2017. Documentation was not available during the November 16, 2017 annual inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility/Program Director will generate an annual report to publically announce names of officers, and directors. This report will be advertised in The Brookville Mirror Newspaper. The Facility/Program Director will complete an annual report that includes the required information each year and make it available to the public each year. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent from the client prior to disclosure in one of four client records reviewed on November 16, 2017.
Client #2 had a release of information form signed by the client on 10-23-2017. The release of information failed to include to whom the information would be disclosed, and the dated signature of the witness.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility shall ensure that all consents are properly completed, including whom the information will be released and a dated signature of a witness. The Facility/Program Director will be in charge of reviewing all forms for accuracy. Client #2 has revised and updated information on the release form and has been signed and dated by a witness. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to include the type and frequency of services on the treatment plan in three of three client records reviewed on November 16, 2017.
The treatment plans reviewed for Client #1, #2, and #3 failed to include the documentation of the type and frequency of treatment and rehabilitation services.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility/Program Director will ensure that the Treatment Plans include documentation for the type and frequency of treatment. All client folders have been reviewed and corrected. The Facility/Program Director has reviewed changes on treatment plan with Client #1,#2,and #3. |