INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4 - 5, 2016 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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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The narcotic treatment physician failed to document the basis for determining current dependency in two of three detoxification patient records reviewed during the licensing and buprenorphine monitoring inspection conducted on October 4 - 5, 2016.
Client #1 - Patient was admitted to detox on 4-25-2016, and was transferred to residential treatment on 4-28-2016.
Client #2 - Patient was admitted to detox on 5-9-2016 and was discharged on 5-12-2016.
The findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Manager of Residential Services will submit the following information to our electronic health record company to add this information onto a page in the history and physical. The history and physical is completed by our doctor on every patient when admitted into our facility. The Manager of Residential Services will submit this to our electronic health record company by the date of January 1, 2017.
The Manager of Residential Services will monitor this monthly by conducting random chart audits to ensure that it is being completed ongoingly.
I (Doctors name) am making a face to face determination that(patient name) is a proper candidate for our buprenorphine program due to the following items:
(the list below will have a box to check or mark with an "X")
Patient has been physiologically dependent for at least 1 year
Patient is currently pregnant
Patient has ended treatment with a narcotic (maintenance) treatment provider within the last 6 months
Patient has visual track marks
Daily use of sedative hypnotics or opiates for over 6 months with the use of another mind-altering drug known to have its own withdraw symptom
Patient is currently experiencing withdraw symptoms
The individual is showing high levels of agitation associated with high degrees of drug craving
Individual used high dose/oral/nasal stimulants, or smoke or injects stimulants at least once a day in a cyclic pattern of "run" and is currently within 7 days of such drug use
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of four residential treatment client records during the licensing inspection on October 4 - 5, 2016.
Client record #1 - Client was admitted to residential treatment on April 28, 2016, and was discharged on May 5, 2016. An individual treatment and rehabilitation plan was completed on 5-2-2016, but did not document the type and frequency of services.
Client record #3 - Client was admitted to residential treatment on August 18, 2016, and was discharged on September 14, 2016. An individual treatment and rehabilitation plan was completed on 8-18-2016, but did not document the type and frequency of services.
Client record #5 - Client was admitted to residential treatment on March 30, 2016, and was discharged on May 3, 2016. An individual treatment and rehabilitation plan was completed on 4-4-2016, but did not document the frequency of services.
Client record #6 - Client was admitted to residential treatment on July 25, 2016, and was discharged on August 29, 2016. An individual treatment and rehabilitation plan was completed on 7-29-2016, but did not document the frequency of services.
The findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Assistant Director will have the EHR vendor push the type and frequency from the initial treatment plan to the master treatment plan and the counselor can make appropriate changes as needed. This was completed by 10/14/2016. The manager of each unit will monitor this throughout the year during paperwork signing to ensure compliance. |
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
The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of two outpatient client records reviewed during the licensing inspection on October 4 - 5, 2016.
Client record #9 - Client was admitted to outpatient treatment on April 5, 2016, and was discharged on August 17, 2016. An individual treatment and rehabilitation plan was completed on 5-6-2016, but did not document the frequency of services.
Client record #10 - Client was admitted to outpatient treatment on June 16, 2016. An individual treatment and rehabilitation plan was completed on 7-28-2016, but did not document the frequency of services.
The findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Assistant Director will have the EHR vendor push the type and frequency from the initial treatment plan to the master treatment plan and the counselor can make appropriate changes as needed. This was completed by 10/14/2016. The manager of each unit will monitor this throughout the year during paperwork signing to ensure compliance. |