INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent for the disclosure of information in one of five applicable records reviewed.
Client #4 was admitted on August 23, 2023 and still a current client. No informed and voluntary consent for the release of information was signed by the client for the funding source. Facility staff confirmed information was disclosed without a release of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Two Roads will obtain informed client voluntary consent for the disclosure of information from active clients. Director and staff will continually inspect files to ensure support for all clients |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the specific information to be disclosed in two of five applicable records reviewed.
Client #2 was admitted on July 5, 2023 and still a current client. On July 5, 2023 the client signed an informed and voluntary consent to release information to their funder which did not include the specific information to be disclosed.
Client #3 was admitted on August 4, 2023 and still a current client. On August 4, 2023 the client signed an informed and voluntary consent to release information to probation which did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All client charts will indicate specific information to be disclosed on all informed and voluntary consent forms.
All client intakes are completed by therapist on completion of intake. The charts will be reviewed by office manager to ensure all information is correct and complete. Appropriate information will then be dispersed to appropriate departments.
Office manager will review all current charts. Office manager will then identify any information that needs to be corrected, updated and have client resign to update and correct current information on releases. |
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.
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Observations
Based on a review of client records, the facility failed to document an attempted follow up with clients following discharge from the facility in one of two applicable records reviewed.
According to agency policy and procedure manual, follow up with both successful and unsuccessful discharges are to be completed within 7 days of discharge.
Client #7 was admitted on January 21, 2022 and successfully discharged on September 20, 2023. No follow up attempts were documented for this client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Two Roads will ensure that all discharged individuals will receive follow up contact or attempted to contact.
Therapist will do intake and complete appropriate paperwork with signatures and complete all forms.
Office manager will be responsible for follow ups after discharge. This will be conducted thru mail. Therapist will be responsible to initiate phone calls as per protocol for follow up after discharge from program. If client consents in aftercare plan.
Documentation of date, time and method of type and outcome of contact will be made by whom initialed. Office manager by written correspondence, therapist by
verbal contact.
Office manager will monitor process. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a review of the physical plant, the facility failed to display hours of operation conspicuously to the general public for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Two Roads has corrected this issue, and the hours of operation has been displayed in the office waiting room and in lobby.
Office manager will monitor signage to insure that is up to date with all current information including closure dates of holiday or any variances that may occur.
This will be monitored monthly at same time as our fire drill, at beginning of every month. |