INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 6-7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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:
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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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client in three of eleven client records.
Client # 3 was admitted into detox on July 23, 2020 and discharged on July 26, 2020. Information was sent to a laboratory for a urinalysis. The was no release of information documented for the laboratory.
Client # 4 was admitted into detox on June 12, 2020 and discharged on June 16, 2020. Information was sent to a laboratory for a urinalysis. The was no release of information documented for the laboratory.
Client # 5 was admitted on March 15, 2021 and was still an active client at the time of the inspection. A letter was sent to a county government agency on March 15, 2021. There was no release of information documented for the county government.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 9 - 11, 2019 annual licensing inspection.
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Plan of Correction
Beginning in March 2021, consents are completed within the Electronic Health Record. The consents will continue to be submitted into EHR.
Effective immediately, program supervisors will re-educate staff regarding 709.28 Confidentiality regulation on obtaining a consent to release protected health information of client. In addition, all patients will have an informed and voluntary consent on file for each consumer regarding PHI information released effective May 1, 2021.
Effective immediately, specific information to be released will be monitored to ensure specific information to disclose is on the completed Release of Information on file before any PHI is released. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to document a release of information that included the name of the person, agency, or organization to whom disclosure is made in three of eleven client records.
Client # 1 was admitted to detox on November 30, 2020 and discharged on December 3, 2020. There were two releases signed by the client on November 30, 2020 that did not include the name of the person, agency, or organization to whom disclosure is to be made.
Client # 2 was admitted to detox on October 23, 2020 and discharged on October 28, 2020. There were six releases signed by the client on October 23, 2020 that did not include the name of the person, agency, or organization to whom disclosure is to be made.
Client # 3 was admitted to detox on July 23, 2020 and discharged on July 26, 2020. There was a release signed by the client on July 23, 2020 that did not include the name of the person, agency, or organization to whom disclosure is to be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning in March 2021, consents are completed within the Electronic Health Record. The consents will continue to be submitted into EHR.
Effective immediately, program supervisors will re-educate staff regarding 709.28 Confidentiality regulation on obtaining a consent to release protected health information of client and completing the Release of Information accurately to include: the name of the person, agency, or organization to whom disclosure is to be made. In addition, all clients will have a release of information that identifies the name of the person, agency, or organization to whom the disclosure is made effective May 1,2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure the name of the person, agency, or organization to whom disclosure is to be made is on the completed Release of Information on file. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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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 the review of client records, the facility failed to document a release of information that included the specific information to be disclosed in eleven of eleven client records.
Client # 1 was admitted to detox on November 30, 2020 and discharged on December 3, 2020. Urine samples were released to a laboratory. The release, dated November 30, 2020, did not include that urine samples could be released.
The client record documented that information provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 2 was admitted to detox on October 23, 2020 and discharged on October 28, 2020. Urine samples were released to a laboratory. A release, dated October 23, 2020, did not include urine samples could be released.
The client record documented that information provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 3 was admitted to detox on July 23, 2020 and discharged on July 26, 2020. The client record documented information that was provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 4 was admitted to detox on June 12, 2020 and discharged on June 16, 2020. The client record documented information that was provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 5 was admitted on March 15, 2021 and was still an active client at the time of the inspection. The client record documented information that was provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 6 was admitted on March 11 , 2021 and was still an active client at the time of the inspection. The client record documented information that was provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 7 was admitted on February 25, 2021 and was still an active client at the time of the inspection. The client record documented information that was provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 8 was admitted on June 7, 2020 and discharged on July 2, 2020. The client record documented information that was provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 9 was admitted on December 1, 2020 and discharged on January 4, 2021. The client record documented information that was provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5
Client # 10 was admitted on November 12, 2020 and discharged on January 28, 2021. Information was sent to the employer. A release of information to an employer, dated November 20, 2020, did not include the specific information to be released.
The client record documented that information provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
Client # 11 was admitted on August 21, 2020 and discharged on September 29, 2020. A release of information to a family member, dated August 24, 2020, did not include the specific information to be released.
The client record documented that information provided to a government agency exceeded that which is permitted by 4 Pa Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning in March 2021, consents are completed within the Electronic Health Record. The consents will continue to be submitted into EHR.
Effective immediately, program supervisors will re-educate staff regarding 709.28 Confidentiality regulation on obtaining a consent to release protected health information of client and completing the Release of Information accurately to include: specific information to be disclosed. In addition all clients will have a release of information with specific information to be disclosed effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure specific information to disclose is on the completed Release of Information on file. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client, that the client was notified that no client may be deprived of a civil right solely by reason of treatment in eleven of eleven client records.
Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 did not document notification of this right.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure all components of the Client Rights are included in the Client Rights signature page.
Effective immediately, program supervisors will re-educate staff regarding 709.30 Client Rights statement and regulations, including the, and Client Rights signature page.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Client's rights will be signed by all patients at their next session effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client that the client was notified of the right the client may not discriminate in the provision of services on the basis of age, ethnicity, natural origin, marital status, sexual orientation and handicap or religion in eleven of eleven client records.
Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 did not document notification of these rights.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure all components (The project may not discriminate in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion) of the Client Rights are included in the Client Rights signature page.
Effective immediately, program supervisors will re-educate staff regarding 709.30 Client Rights statement and regulations, including the policies and procedures, and not discriminating in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Client's rights will be signed by all patients at their next session effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client that the client was notified of the right that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records eleven of eleven client records.
Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 did not document notification of this right.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure it includes: clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Effective immediately, program supervisors re-educated staff regarding 709.30 (5) client rights; clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Client's rights will be signed by all patients at their next session effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client that the client was notified that the client has the right to submit memoranda to their own records in eleven of eleven client records.
Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 did not document notification of this right.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure it includes: clients have the right to submit rebuttal data or memoranda to their own records.
Effective immediately, program supervisors will re-educate staff regarding 709.30 (6) client rights; clients have the right to submit rebuttal data or memoranda to their own records.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Client's rights will be signed by all patients at their next session effective May 1, 2021.
Effective immediately, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
The facility failed to document that the client record was properly countersigned by the medical director or a narcotic treatment physician in one of one client record.
Client # 4 was admitted into detox on June 12, 2020 and discharged on June 16, 2020. A physical exam was completed by the Physician's Assistant on June 12, 2020. The physical exam was not countersigned by the medical director or a narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 23, 2021, Director of Clinical Care Services educated the Medical Director the necessity to sign off on records.
Effective immediately, program supervisors will re-educate staff, including all physician assistant, CRNP, and Medical Physician regarding the 715.6(e) physician staffing regulation that records are countersigned by the medical director if functions are completed by a physician assistant or CRNP. In addition, the medical director will review all physical exams completed by the physician's assistant and countersign required documents including physical exams effective April 23, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure documents completed by a physician assistant or CRNP are countersigned by the medical director. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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