INITIAL COMMENTS
|
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:
|
Plan of Correction
|
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.
|
Observations
Based on three of eight 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 # 1 was admitted on March 6, 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 March 6, 2023, to two county agencies, probation office, physician office, and family member did not provide the specific information that was to be disclosed.
Client # 6 was admitted on March 6, 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 March 6, 2023, to a probation office and healthcare facility did not provide the specific information that was to be disclosed.
Client # 8 was admitted on February 24, 2023 and was discharged on May 12, 2023. An informed and voluntary consent signed by the client for the disclosure of information dated February 24, 2023, to a county agency, attorney, probation office, and family member did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
|
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. |
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.
|
Observations
Based on three of eight 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 # 1 was admitted on March 6, 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 March 6, 2023, to two county offices did not include the purpose of the disclosure.
Client # 3 was admitted on April 19, 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 April 19, 2023, to a county office did not include the purpose of the disclosure.
Client # 8 was admitted on February 24, 2023 and was discharged on May 12, 2023. An informed and voluntary consent signed by the client for the disclosure of information dated February 24, 2023, to a county office did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
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. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on three of eight client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 2 was admitted on April 4, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on April 11, 2023, and updated June 11, 2023, and August 11, 2023, that indicated an individual session to occur one time a week. A review of progress notes and record of service did not document individual sessions the weeks of June 27-July 2, July 3-9, July 10-16, July 17-23, July 24-30, August 1-7, and August 8-14, 2023.
Client # 4 was admitted on May 11, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on June 8, 2023, indicates an individual session to occur one time a week. A review of progress notes and record of service did not document individual sessions the weeks of June 18-24, July 23-29, August 6-12, 2023.
Client # 8 was admitted on February 24, 2023 and was discharged at May 12, 2023. A comprehensive treatment and rehabilitation plan developed on March 3, 2023, indicates an individual session to occur one time a week. A review of progress notes and record of service did not document individual sessions the weeks of March 12-18, April 23-29, and April 30-May 6, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program supervisors developed two separate workflows on 9/21/2023. The first is a workflow entitled "Frequency of care change" to address documentation requirements per the 709.92 (C) regulations for when a client changes their frequency of care.
The second workflow created by program supervisors on 9/21/2023 entitled "Engagement-no show or cancelation outreach" addresses the specific expectations for engagement per the 709.92 (C) regulations. These new workflows will ensure that staff are following through with client engagement and are aware of how to properly document when there is a change in frequency of a client's care. Properly documenting a change in frequency of the client's care will allow staff to ensure that all individual services are properly documented in the EHR. Supervisors will be responsible for educating staff about the workflows listed above by 10/2/2023. This workflow will also be re-visited by the supervisor in routine supervision with individual staff. Supervisors will also instruct staff to complete a treatment plan review each time a client's frequency of care changes by 10/2/2023. When that conversation takes place. This will better allow for a treatment plan review to be completed each time the frequency changes effective 10/2/2023. |