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. |
709.93(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 # 5 was admitted on June 17, 2021 and discharged on July 6, 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
Supervisor added the 7-day Follow-up letter document to the verification checklist on 9/2/21. The Customer Care Associate reviews the checklist to ensure all components of the chart, including the follow-up letter, are present prior to closing the client chart. Supervisor educated CCA of the additional item added to checklist. Effective 9/10/21.
For 1 of the 4 charts noted, the client was receiving education-only services, no treatment, therefore no follow-up letter is required or indicated. Our discharge roster does not indicate LOC, therefore the auditor was unaware this client was education only. Billing and Administrative Manager will add the LOC on the discharge roster by 9/10/21. Supervisor will educate staff on the additional change to the discharge roster. Effective 9/30/21
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