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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of five personnel records, the facility failed to ensure one counselor met the qualifications for the position.
Employee # 7 was hired as a counselor on March 14, 2023 and was still in this position at the time of the inspection. Employee #7 had a qualifying master ' s degree however she did not have documentation of a practicum or three months of qualifying clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 10/2/2023 program director and supervisors will confirm with HR that the perspective candidate meets the required qualifications for their position according to 704.7 (b) and/or meet the qualifications for a counselor assistant in 704.9. The program director or supervisor will request detailed documentation of previous qualification to determine placement in the correct position prior to the applicants first interview. If an applicant is hired as a counselor assistant, the program supervisor will adhere to the regulatory requirements of a counselor assistant according to 704.9 which includes ensuring that clear documentation of required supervision is obtained by the supervisor. If an applicant does not meet the regulatory requirements for the position, the program director will request an exemption as needed. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on August 30, 2021 and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than August 30, 2022. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection and HIV/AIDS training was not completed until June 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Twin Lakes program supervisors and director updated each location's version of training tracking information.
One unified training checklist entitled "New Hire Checklist " has been created for all staff effective 9/25/2023. All required DDAP training is incorporated into this database to ensure that training is being obtained within appropriate date ranges per the 704.11 (C) regulatory requirements. All program supervisors will utilize the unified training checklist as a streamlined working document. The director met with program supervisors on 9/25/2023 to review this new process. In addition, supervisors will review this new hire checklist with each staff member during regular supervision and document the change in their supervision notes effective 9/25/2023. The supervisor will also document the progress of the staff's training hour completion in monthly supervision beginning 9/25/2023. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on one of one applicable residential client record reviewed, the facility failed to provide documentation of the emergency contact being notified when a client leaves against medical advice in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate the next of kin be notified of the client leaving against medical advice within twelve hours of leaving the facility.
Client # 14 was admitted on December 21, 2022 and was discharged on December 31, 2022. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 12, 2023 annual licensing inspection.
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Plan of Correction
Twin Lakes program supervisor will perform a reeducation with staff on the necessity of completing an informational note in the EHR when next of Kin (as listed on their NOK consent) is contacted per the 709.24 (a) (3) regulation unless the consent is revoked by the client by 10/2/2023. Supervisors also developed a workflow in which the Administrative Assistants will be responsible for performing a weekly check for clients that have left ama. Effective 10/2/2023, they will search for that client in the EHR and ensure that an informational note was entered regarding contacting the NOK. If there is no note, the administrative assistant will contact the staff responsible via email and alert them that they need to enter a note into the EHR. As a double check they will also cc the program supervisor to ensure follow through. The supervisor will follow up with the staff during supervision and address any trends found by the administrative assistants with the staff effective 10/2/2023. |
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.
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Observations
Based on two of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the clients for the disclosure of information contained in the client record.
Client # 9 was admitted on July 28, 2023 and was still active at the time of the inspection. Authorization for funding occurred on July 28 and August 11, 2023. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source prior to these authorizations.
Client # 12 was admitted on March 8, 2023 and was discharged April 12, 2023. Authorization for funding occurred on March 8, March 13, April 3, and April 11, 2023. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source prior to these authorizations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Twin Lakes 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. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on one of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 9 was admitted on July 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 July 28, 2023, to two county agencies did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 27, 2021, August 11, 2021, and August 12, 2022 annual licensing inspections.
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Plan of Correction
Twin Lakes 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. |
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 six of fourteen 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 # 7 was admitted on July 26, 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 August 9, 2023, to an outside source did not include the purpose of the disclosure.
Client # 8 was admitted on July 26, 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 July 26, 2023, to a county office did not include the purpose of the disclosure.
Client # 9 was admitted on July 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 July 28, 2023, to a two county office's did not include the purpose of the disclosure.
Client # 11 was admitted on January 9, 2023 and was discharged on March 17, 2023. An informed and voluntary consent signed by the client for the disclosure of information dated July 28, 2023, to a county office did not include the purpose of the disclosure.
Client # 13 was admitted on April 17, 2023 and was discharged on May 5, 2023. An informed and voluntary consent signed by the client for the disclosure of information dated April 17, 2023, to a county office did not include the purpose of the disclosure.
Client # 14 was admitted on December 21, 2022 and was discharged on December 31, 2022. An informed and voluntary consent signed by the client for the disclosure of information dated December 21. 2022, to a county office 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
Twin Lakes 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. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on one of one applicable residential client record reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days.
Client # 11 was admitted on January 9, 2023 and was discharged March 17, 2023. A treatment and rehabilitation plan was developed on January 19, 2023. A treatment and rehabilitation plan update was due no later than February 19, 2023. There was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Twin Lakes program supervisors identified that there was an issue with the EHR in which client assignments were not being completed correctly. This error created a deficiency in the EHR's ability to identify when txp reviews needed to be completed. Therefore, supervisors will perform a reeducation with front office staff by 10/2/2023. This reeducation will address the importance of the intake coordinator's/ administrative assistants' responsibility to properly assign intake and stepdown clients in the EHR. Administrative staff will review intakes weekly to ensure patients are assigned correctly in the EHR starting 10/2/2023 for veteran administrative assistants. For new administrative assistants hired after the 2023 DDAP licensing this workflow will be implemented by 1/2/2024 due to new staff hiring dates. Also, weekly reports will be pulled from the EHR by administrative assistants to ensure all patients have a current txp/ txp review completed by 10/2/2023 for veteran administrative assistants and by 1/2/2024 for administrative assistants hired after the 2023 DDAP licensing. This will further ensure that if a client changes their level of care, that their treatment plan review is accurately reflected in the dashboard report. This process will also allow for compliance to continue to pull accurate monthly txp review tracking reports to ensure that txp reviews are being completed timely by staff. Compliance will continue to pull txp reports and send to the supervisors monthly. Supervisors will review the reports and assess for missing or late documentation. Supervisors will then address the lacking documentation with staff immediately via email as well as during supervision effective 10/2/2023. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for obtaining an informed and voluntary consent from the client that included the specific information to be disclosed were submitted and approved by the Department for the April 27, 2021, August 11, 2021, and August 12, 2022, annual licensing inspections. This deficiency was again found during this licensing inspection.
A plan of correction for contacting a client ' s emergency contact within twelve hours of a client leaving against medical advice was submitted and approved for the August 12, 2022 annual licensing inspection. This deficiency was again found during this licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will develop a tracking system to identify each element of corrective action based on our DDAP licensing Audit no later than 10/2/2023. This tracker will include identification of the issue/citation, Program(s) impacted, Specific action to be taken, Staff responsible for implementation of action steps, due date of each action step, completion date for each Action item and an ongoing verification plan. The Facility Director will meet as needed and not less than monthly with each department head to review progress on the submitted CAP beginning in October 2023. If an extension or revision of the CAP seems indicated, the Facility Director will contact DDAP through our assigned auditor to request a modification to the CAP within 15 days of identifying the need. |