INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14-15, 2014 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.
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Plan of Correction
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in one of the one required record.
The findings include:
Eleven client records were reviewed on July 14-15, 2014. Three of the eleven client records were from the partial hospitalization activity. One of those three records was required to have treatment plan updates at least every 30 days.
Client # 7 was admitted to treatment on 2-14-2014 and was discharged on 4-1-2014. The comprehensive treatment plan was completed on 2-18-2014. The treatment plan update was due by 3-18-2014, but was not documented as of the date of the inspection.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
The Outpatient Supervisor will educate staff regarding paperwork due dates during his next outpatient staff meeting on 9/30/14. He will also complete 3 chart audits per counselor per month to ensure paperwork completion by the due dates. |
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. The consent shall be in writing and include, but not be limited to:
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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 in nine of eleven client records reviewed.
The findings include:
Eleven client records were reviewed on July 14-15, 2014. Nine of the eleven client records were required to include an informed and voluntary consent from the client. The purpose was not identified in records #1, 2, 3, 4, 5, 7, 8, 9 and 10.
Client #1 was admitted to treatment on 12-13-2013, and was discharged on 12-16-2013. A release of information for a funding source was signed on 12-13-2013, and did not include a relevant purpose of disclosure.
Client #2 was admitted to treatment on 7-10-2014, and was transferred on 7-13-2014. A release of information for a funding source was signed on 7-10-2014, and did not include a relevant purpose of disclosure.
Client #3 was admitted to treatment on 4-22-2014, and was discharged on 5-6-2014. A release of information for two funding sources was signed on 4-22-2014, and did not include the purpose of disclosure.
Client #4 was admitted to treatment on 7-1-2014. A release of information for a funding source and for an assistance office was signed on 7-1-2014, and did not include a relevant purpose of disclosure.
Client #5 was admitted to treatment on 6-19-2014. A release of information for a funding source was signed on 6-19-2014, and does not include a relevant purpose of disclosure. A release of information for a person was signed on 6-30-2014, and did not include the purpose of disclosure.
Client #7 was admitted to treatment on 2-14-2014, and was discharged on 4-1-2014. A release of information for a funding source was signed on 2-14-2014, and did not include a relevant purpose of disclosure.
Client #8 was admitted to treatment on 4-23-2014, and was discharged on 5-8-2014. A release of information for a funding source was signed on 4-23-2014, and did not include a relevant purpose of disclosure.
Client record #9 was admitted to treatment on 2-25-2014. A release of information for a funding source was signed on 2-25-2014, and did not include a relevant purpose of disclosure.
Client #10 was admitted to treatment on 4-8-2014 and was discharged on 6-25-2014. A release of information for a family member was signed on 4-1-2014, and did not include the purpose of disclosure.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
The Executive Director and the Assistant Director will conduct a staff-wide training on confidentiality and how to complete a 5 point release prior to 9/30/14. Each supervisor will conduct 3 chart audits per month per counselor/nurse to ensure releases are completed in an appropriate manner. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that work done by the client at the project as an integral part of the treatment and rehabilitation plan in three of eleven client records reviewed.
The findings included:
Eleven client records were reviewed on July 14-15, 2014. Three of the eleven were required to document verification of work as an integral part of the treatment and rehabilitation plan. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records #3, 4 and 5.
Client #3 was admitted to treatment on 4-22-2014, and was discharged on 5-6-2014. The treatment plan was completed on 4-22-2014, and failed to include the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #4 was admitted to treatment on 7-1-2014. The treatment plan was completed on 7-7-2014, and failed to include the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
Client #5 was admitted to treatment on 6-19-2014. The treatment plan was completed on 6-23-2014, and failed to include the work done by the client at the project as an integral part of the treatment and rehabilitation plan.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
The Executive Director and the Assistant Director will conduct a training for counselors and nursing staff on treatment planning prior to 9/30/14. Staff will be educated to include work therapy as a goal on the treatment plan. Each supervisor will conduct 3 chart audits per month per counselor/nurse to ensure treatment plans include work therapy under interventions. |
709.93(a) 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:
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Observations
Based on a review of the client records, the facility failed to provide complete medication records in two of three client records reviewed.
The findings include:
Eleven client records were reviewed on July 14-15, 2014. Three of the eleven client records were reviewed for the outpatient activity. All three client records were required to include a complete medication record. Two of the three records, #10 and 11, failed to document complete medication records.
Client #10 was admitted to treatment on 4-8-2014 and was discharged on 6-25-2014. The client's history indicated the client was on medication, but there was no copy of a medication record in the client record.
Client #11 was admitted to treatment on 3-18-2014 and was discharged on 7-2-2014. The medication record failed to document the medication name and frequency.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
The Outpatient Supervisor will educate staff regarding completion of medical histories and medical records with documentation of such durng his next outpatient staff meeting on 9/30/14. He will also complete 3 chart audits per counselor per month to ensure medical histories and medical records are completed appropriately. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a physical plant inspection conducted with facility staff on July 15, 2014, the facility exceeded the licensed capacity for the number of clients in the detoxification activity.
The findings include:
The inpatient non-hospital detoxification activity capacity is seven. At the time of the physical plant inspection, there are eight beds constructed. The findings were reviewed with the director and were not disputed.
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Plan of Correction
The Director of Nursing will ensure that only seven beds are constructed in detox at all times. The additional bed will be removed prior to 8/15/14 by the Director of Nursing and the MSH Supervisor. |