INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8-11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the project fiscal management, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the fiscal year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WBH @ Twin Lakes will work with UPMC's financial auditor to ensure that the 2021 audit is completed in a timely manner. If the UPMC financial auditor informs the Director that the audit will be late, Director will request an exenstion to DDAP. Effective 9/1/2021. |
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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 5 was admitted on April 5, 2021 and was discharged on May 27, 2021. Correspondence with funding sources and authorization verifications occurred on March 26, 2021, April 6, 2021, and April 9, 2021 without an informed and voluntary consent from the client for the disclosure of information. Also, A correspondence with probation occurred on May 28, 2021 without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 5, 2021 annual inspection.
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Plan of Correction
Supervisors will re-educate staff by September 17, 2021 to obtain an informed and voluntary consent for the disclosure of information contained in the client record.
During monthly chart audits, supervisors will review client's records to ensure that all releases of information are obtained.
Effective 9/17/2021
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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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to keep the specific information disclosed limited to 255.5 (a) (6) for an employer.
Client # 1 was admitted on June 4, 2021 and was still active at the time of the inspection. A correspondence with an employer dated June 4, 2021 provided more information than whether the client is or is not in treatment. Also, an informed and voluntary consent from the client for the disclosure of information allowed the release of more information than permitted by 255.5 (a)(6).
Client # 7 was admitted on March 25, 2021 and was discharged on July 27, 2021. A family session occurred with the client ' s father on July 27, 2021. The informed and voluntary consent from the client for the disclosure of information contained in the client record did not allow disclosures of information beyond 255.5 (b). Also, a correspondence with an "other agency" provide information specific to what the client relapsed on. The informed and voluntary consent from the client for the disclosure of information contained in the client record did not allow disclosures of information beyond 255.5 (b).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisors will re-educate staff by September 17, 2021 to obtain an informed and voluntary consent for the disclosure of information to keep the specific information disclosed limited to 255.5 (a) (6) for an employer.
During supervision with staff and while conducting monthly chart audits, supervisors will review client's records to ensure that all releases of information obtained keep the disclosed limited to 255.5(a)(6) for employer. Effective 9/17/2021.
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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 one of three discharged client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 7 days by letter.
Client # 7 was admitted on March 25, 2021 and discharged on July 27, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Currently, all UPMC WBH at Twin lakes customer Care associates maintain a ledger recording when -day follow-up letters are sent. Beginning 9/15/2021, supervisors will review that ledger and compare it to the Discharge Summary report (showing all clients discharged) at least twice per week. The supervisor will prompt the customer Care associate if any recent discharged clients have not yet had a 7-day follow-up letter sent. |