INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2010 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 October 15, 2010.
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Plan of Correction
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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 plan review and updates within sixty days, as required by regulation, in two of three client records.
The findings include:
Three client records were reviewed for treatment plan updates on September 15, 2010. Per the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan review and updates within sixty days, in two of three client records reviewed, specifically client records # 4 and 5
Client # 4 was admitted on May 27, 2010. The comprehensive treatment plan was completed on June 10, 2010. The first treatment plan update was due no later than August 10, 2010. The first treatment plan update was not completed until August 26, 2010.
Client # 5 was admitted on May 18, 2010. The comprehensive treatment plan was completed on May 18, 2010. The first treatment plan update was due no later than July 18, 2010. The first treatment plan update was not completed until July 26, 2010.
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Plan of Correction
The supervisor will educate the staff members on paperwork due dates during their weekly supervision. They will be instructed to use the paperwork checklist to monitor these due dates closer. This will be completed by 10/29/2010 and will be monitored via chart audits (2 per counselor per month) to ensure that it does not re-occur. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of outpatient client records, the facility failed to failed to document an aftercare plan that included goals with time frames, support services, a contact person and/or the reentry process in three of three client records reviewed.
The findings include:
On September 15, 2010 three outpatient client records were reviewed for documentation of an aftercare plan. The facility failed to document an aftercare plan that included goals with time frames, support services, a contact person and/or the reentry process in three of three records reviewed, specifically, client records # 4, 5, and 6.
Client #4 was admitted on May 27, 2010 and discharged on September 2, 2010. The aftercare plan was completed on September 2, 2010. The goals listed in the aftercare plan did not specify timeframes for the goals to be completed, but instead listed a start date only. Furthermore, the aftercare plan did not include a reentry process or the contact person for reentry.
Client #5 was admitted on May 18, 2010 and discharged on August 24, 2010. The aftercare plan was completed on August 24, 2010. The goals listed in the aftercare plan did not specify timeframes for the goals to be completed, but instead listed a start date only. Furthermore, the aftercare plan did not include a reentry process or the contact person for reentry.
Client #6 was admitted on April 28, 2010 and discharged on August 25, 2010. The aftercare plan was completed on August 25, 2010. The goals listed in the aftercare plan did not specify timeframes for the goals to be completed, but instead listed a start date only. Furthermore, the aftercare plan did not include a reentry process or the contact person for reentry.
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Plan of Correction
The Director will amend the aftercare plan to have a more clear beginning date and she will add a completion date. She will also add a section detailing how to re-enter treatment and who they can contact to re-enter. Afterwards, this form will be approved by the QI team. Following approval, each supervisor will educate staff on proper use of the new form. This finding will be corrected by November 1, 2010. In order to ensure that this does not re-occur, the supervisors will audit 2 charts per counselor per month. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
On September 15, 2010 five personnel records were reviewed. Employee #3 was promoted from a counselor to an OP clinical supervisor on March 15, 2010. After a review of employee #3's resume, it was found he had less than two years experience as supervisor in a clinical setting. Employee #3's personnel record did not have documentation of a core curriculum in clinical supervision.
On September 15, 2010 an interview was conducted with the project director who confirmed that employee number #3 had not received a core curriculum in clinical supervision.
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Plan of Correction
The outpatient supervisor will monitor the BDAP website to see when the next training is offered. He will then register for the next training offered within traveling proximity. In order to ensure that this does not happen again, the Director will send all staff to the supervisor training prior to promotion when possible and if not, she will send them to the next available training within traveling proximity. This should be corrected by 12/31/2010. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an interview with the facility director and a review of staff CPR and first aid documentation, the facility failed to ensure that a sufficient number of staff persons trained in first aid skills are present during the project's hours of operation.
The findings include:
On September 15, 2010 the facility presented the Staffing Requirement Facility Summary Report to the licensing specialist and there were no first aid certification cards attached.
An interview with the facility director confirmed that none of the staff members had documentation of first aid training.
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Plan of Correction
The Director will schedule a trainer to come to Twin Lakes Center to train staff members in First Aid before 11/1/2010. The Director will ensure that all new staff will be trained in First Aid as soon as possible after their hire date and this will be monitored in our monthly QI meeting. |