INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, client records for the project were reviewed August 15-17, 2023, at the Twin Lakes Center, Inc. Somerset location and the physical plant inspection conducted on August 18, 2023, 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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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included the purpose of the disclosure in one of seven records.
Client # 2 was admitted on February 3, 2023 and was still active at the time of the inspection. An informed and voluntary consent signed by the client dated February 3, 2023 to a county agency, probation office, attorney, and family member did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisors will create a unified example template of a properly completed release of information. Staff completing releases can reference this example by 10/2/2023. This example form will fulfill the requirements of the 709.28 (C) regulatory code. The example created by the supervisors will show the areas that need information input by staff highlighted for ease of access. A hard copy of this example will be kept in the Administrative Assistant's office and copies will be made and dispersed to each necessary staff member via email by 10/2/2023. This will ensure that staff can use the example as a guide/ comparison to ensure completion when filling out consents. Administrative Assistant at each location will be educated in the process of auditing consents to ensure they fulfill the 709.28 (C) requirements by 10/2/2023. Counselors will use the highlighted example and will be comparing each received consent to it, to ensure correct completion before sending it to the administrative assistant for review. This process will also be added to the new hire orientation for all staff in the future to ensure fluidity by 10/2/2023. Twin Lakes director Paul Cannon will be responsible for printing colored, black releases of information for staff by 10/2/2023. These blank consents will have a highlight over the areas where staff need to input information. If an administrative assistant is unavailable for any reason at the time of counselor's completion of the consent, the counselor will be instructed to place the completed consent in the administrative assistant's mailbox before it is sent out to ensure that it is still going through the double check process. Administrative assistants will also complete a monthly summary of chart audit findings in regard to consents that have been completed for clients at their site. They will be added to the monthly clinical huddle starting 10/2/2023 and will report their findings to identify any systematic issues with clinicians completing consents |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on three of seven client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client, within 30 days, as indicated in the facility policy and procedure manual.
Client # 1 was admitted on January 11, 2023 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than February 11, 2023. There was no documentation of a completed individual treatment and rehabilitation plan in the client record.
Client # 4 was admitted on April 19, 2023 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than May 19, 2023. There was no documentation of a completed individual treatment and rehabilitation plan in the client record until June 1, 2023.
Client # 5 was admitted on April 14, 2023 and was discharged June 26, 2023. An individual treatment and rehabilitation plan was due no later than May 14, 2023. There was no documentation of a completed individual treatment and rehabilitation plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
UPMC Western Behavioral Health at Twin Lakes has a process for tracking due dates regarding treatment plans and other mandatory documentation. In a review of the findings of this audit, we became aware that not all clients were being added to the tickler system in the EHR at the time of admission. As a result, the tracking system was not showing that documentation was due. To fix this problem, Twin lakes will implement the following process. Each week the AA will review admissions from the prior week to confirm that the client has been correctly entered into the documentation tracking system. They will also verify if any treatment plans need to be developed, signed, or reviewed by the client by reviewing the client's documentation in the EHR. The AA will prepare and send an email to the treating clinician and their supervisor as a reminder to develop or obtain the client signature on any treatment plan that is missing. The supervisor will follow up in the next scheduled supervision to confirm proper completion. All Administrative and clinical staff will be made aware of this process during scheduled Staff meetings and one-on-one education throughout the month of October. This process will be fully in effect by 10/31/2023. |
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 one of three applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days.
Client # 4 was admitted on April 19, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 1, 2023. A treatment and rehabilitation plan update was due no later than August 1, 2023; however it was not documented until August 16, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor has identified one clinician at the Ebensburg location who is receiving routine education/ supervision to improve their documentation on an ongoing basis since 6/1/2023. The supervisor will continue to meet with this clinician regarding the requirements of txp's per the 709.92 (b) regulations. Program supervisor will also begin to monitor this clinicians txp's/ txp reviews to ensure that regulatory requirements are being met effective 10/2/2023. The clinician will be given 6 months to improve their txp documentation in accordance with the requirements. If their documentation skills do not improve enough to meet regulatory requirements by, 3/2024 this said counselor will be subject to further disciplinary action by the program director per the facilities policy "Corrective action and Discharge (HS-HR0704)".
Outpatient program supervisors created a workflow on 9/20/2023 to identify client assignment in the EHR to assist staff with the process of completing txp's/ txp plan updates in accordance with the 709.92 (a) regulatory requirements. This workflow is entitled "Frequency of care change". All staff will be educated by the supervisor on the workflow process by 10/2/2023. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on three of four applicable client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 2 was admitted on February 3, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on February 24, 2023, indicates an individual session to occur one time a week. A review of progress notes and record of service did not document individual sessions the weeks of February 26-March 4, March 12-18, May 7-13, May 21-27, June 25-July 1, July 2-8, and July 30-August 5, 2023.
Client # 4 was admitted on April 19, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on June 1, 2023, and updated August 16, 2023 indicates an individual session to occur one time a week. A review of progress notes and record of service did not document individual sessions the weeks of July 30-August 5, and August 6-12, 2023.
Client # 6 was admitted on November 2, 2022 and was discharged at July 21, 2023. A comprehensive treatment and rehabilitation plan developed on November 11, 2022, indicates an individual session to occur one time a week and groups to occur two times a week. A treatment plan update on March 16, 2023, indicates an individual session occur one time a week. A review of progress notes and record of service did not document individual sessions the weeks of February 26-March 4, April 16-22, April 23-29, May 14-20, May 28-June 3, and June 11-July 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisors developed two separate workflows on 9/21/2023. The first is a workflow entitled "Frequency of care change" to address documentation requirements per the 709.92 (C) regulations for when a client changes their frequency of care.
The second workflow created by program supervisors on 9/21/2023 entitled "Engagement-no show or cancelation outreach" addresses the specific expectations for engagement per the 709.92 (C) regulations. These new workflows will ensure that staff are following through with client engagement and are aware of how to properly document when there is a change in frequency of a client's care. Properly documenting a change in a frequency of the client's care will allow staff to ensure that all individual services are properly documented in the EHR. Supervisors will be responsible for educating staff about the workflows listed above by 10/2/2023. This workflow will also be re-visited by the supervisor in routine supervision with individual staff. Supervisors will also instruct staff to complete a treatment plan review each time a client's frequency of care changes by 10/2/2023. When that conversation takes place. This will better allow for a treatment plan review to be completed each time the frequency changes effective 10/2/2023. |
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 two of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within 7 days by letter.
Client # 5 was admitted on April 14, 2023and was discharged on June 26, 2023. A follow-up letter was due to be sent by July 3, 2023, however, the letter was not sent until August 4, 2023.
Client # 7 was admitted on February 13, 2023 and was discharged on May 18, 2023. 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
Program supervisors developed a workflow on 9/18/2023 for the Administrative Assistants' regarding follow up documentation requirements for discharged clients per the 709.93 (a) (11) regulations. The workflow developed is entitled "Client discharge follow up" and will ensure that any discharges done in that last week of service will receive a follow up letter effective 10/2/2023. To further ensure that a follow-up letter is sent out, Administrative Assistants will review the list of discharged clients from the previous week. They will then contact each clinician via email to ensure that there were no missed clients that had been discharged within the previous week being reviewed. This will serve as a double-check system between the Administrative Assistants and the clinicians. Supervisors will address this workflow with staff also, during ongoing supervision. |