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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Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 2 was admitted on May 23, 2023 and was still active at the time of the inspection. An informed and voluntary consent signed by the client for the disclosure of information dated May 23, 2023, to an outside agency did not include the purpose of the disclosure.
Client # 4 was admitted on June 28, 2023 and was still active at the time of the inspection. An informed and voluntary consent signed by the client for the disclosure of information dated June 28, 2023, to a health facility did not include the purpose of the disclosure.
Client # 7 was admitted on January 10, 2023 and was discharged on May 5, 2023. An informed and voluntary consent signed by the client for the disclosure of information dated January 10, 2023, to an outside agency 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 created a unified example template of a properly completed release of information on 9/25/2023. Staff completing releases will begin referencing this example effective 10/2/2023. This example form fulfills 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 use the example as a guide/ comparison to assist staff's 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 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 will be responsible for printing colored, blank releases of information for staff by 10/2/2023. These blank consents will have a colored 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. Administrative assistant staff 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. |