INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 15 through 17, 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to document follow up information in one of three records reviewed, #6.
|
Plan of Correction
The office secretary will be responsible to complete the follow-ups per policy. The Directors of OP and Residential 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 Directors of OP and Residential Services can do random comparisons of the lists to ensure all follow ups are being completed. The Directors of Residential and OP Services will report on this to the PI Committee on a quarterly basis. |
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.
|
Observations
Based on a review of personnel and training records, the facility failed to document HIV/AIDS training within the first year of employment in one of ten records reviewed, #9.
|
Plan of Correction
Employee #9 has been scheduled for the next available HIV Training, 11/14/07. Supervisors have been reoriented to the policy and will be responsible to insure staff receive the trainings within the specified time period. |