INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2022 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill logs, the facility failed to prepare alternate exit routes.
Sixteen fire drills were conducted between November 2021 through December 2022, all the fire drill logs documented the front exit was utilized.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.28(d)(5)
Fire Safety:
Staff at TRC who are providing fire drills one time per month shall begin using alternative exit routes. There are three paths of exit from Two Roads, including; the elevator, the front stairs facing Main Street, and the back door facing Pickering Street. Staff will be instructed regarding this procedure.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of criteria for admission and involuntary discharge / termination criteria in six of six records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.91(b)(1)
Intake and Admission:
Two Roads will ensure proper documentation and will provide clients with this information during the intake and admission process. Criteria for admission, involuntary discharge, and treatment will be discussed and documented. This will be a dominant focus for TRC. All intake and admission paperwork from this point forward will be accurately documented. Regarding all current and future clients will be complaint. Staff will be instructed regarding this procedure.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plans were reviewed and updated at least every sixty days in four of five client records.
Client #1 was admitted on July 22, 2022 and was discharged on November 1, 2022. A treatment plan was documented on August 5, 2022. A treatment plan update was due by October 5, 2022 and was not documented.
Client #2 was admitted on July 19, 2022 and was discharged on October 28, 2022. A treatment was documented on August 2, 2022. A treatment plan update was due by October 2, 2022 plan and was not documented.
Client #5 was admitted on June 27, 2022 and was still active at the time of the inspection. A treatment plan was documented on August 14, 2022. A treatment plan update was due by October 14, 2022 and was not documented.
Client #6 was admitted on July 26, 2022 and was still active at the time of the inspection. A treatment plan was documented on August 16, 2022. A treatment plan update was due by October 16, 2022 and was not documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 (b)
Treatment and Rehabilitation services:
Two Roads Counseling will ensure proper time frames when completing treatment plans, and treatment plan updates which occur every 60 days, and as required by law. Accurate documentation involving dates and time frames will be provided. Treatment plans from this point forward will be accurately documented. Regarding all current and future clients will be complaint. A Staff will be instructed regarding this procedure.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes in five of six records.
Client #2 was admitted on July 19, 2022 and was discharged on October 28, 2022. Progress notes were not documented on July 19, 26, August 2, 9, 16, 18, 20, 25, September 1, 8, 15, 23, and October 1, 2022, but the record of service document indicated individual sessions occurred on those dates.
Client # 3 was admitted on October 21, 2022 and was still active at the time of the inspection. A progress note was not documented on November 11, 2022, but the record of service document indicated an individual session occurred.
Client #4 was admitted on April 18, 2022 and was still active at the time of the inspection. Progress notes were not documented on June 13, October 6, 13, and November 10, 2022, but the record of service document indicated individual sessions occurred on those dates.
Client #5 was admitted on June 27, 2022 and was still active at the time of the inspection. Progress notes were not documented on October 4 and 11, 2022, but the record of service document indicated individual sessions occurred on those dates.
Client #6 was admitted on July 26, 2022 and was still active at the time of the inspection. Progress notes were not documented on October 11, and November 24, 2022, but the record of service document indicated individual sessions occurred on those dates.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.93 (a)(5)
Client Records:
Proper documentation will be provided in all records, and progress notes will be appropriately placed in each file. This portion of the process falls on me, as I am responsible for all progress notes. I will ensure proper and timely documentation regarding these interactions and other forms of verification. Progress Notes that were missing, from this point forward will be accurately documented. And that all current and future clients will be complaint. This was an oversight that is unacceptable.
Changes in the Administrative Assistant pool at Two Roads Counseling has played a harsh, but temporary situation for us. The staff has settled, and we are able to return to business as usual.
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