INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15-17, 2008 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 and a plan of correction is due on October 20, 2008.
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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 the review of 12 personnel records, one was reviewed as a counselor. The facility failed to document staffing qualifications in one of one personnel record where required.
Findings:
The facility did not provide documentation that the employee's degree had been reviewed by the division and that the degree met the requirements of a counselor in personnel record #4.
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Plan of Correction
Supervisors will be reminded by Director that all degrees not specifically identified as meeting the requirements for staffing qualifications for counselor will be submitted to the department for review and approval. Effective 10/10/08. |
709.82(e)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on the review of administrative documentation on September 15-17, 2008, the facility failed to document that clients were assisted in obtaining supportive services for dental care.
Findings:
The facility did not provide documentation that dental services were available to clients.
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Plan of Correction
A local dental facility has verbally agreed to sign a letter of agreement with this facility to see our patients in need of dental care. The official letter of agreement was mailed out for signatures 10/9/08. If the signed letter is not returned by 10/16/08 a follow up call will be made to obtain the signed letter. |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of administrative documentation on September 15-17, 2008, the facility failed to document that clients were assisted in obtaining supportive services for legal issues.
Findings:
The facility did not provide documentation that legal services were available to clients.
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Plan of Correction
The Director has attempted to have Legal Aid sign a letter of agreement but have not received any response to my requests. The Director will continue to attempt to enter into an agreement with them. In the meantime the Director will also contact some of the attorneys associated with the local Drug Court in an attempt to reach an agreement with them. If the Director is unable to resolve this issue by December 23, 2008 she will contact the department of licensing for further direction and guidance. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of administrative policy and procedures on September 15-17, 2008, the facility failed to formulate a complete policy regarding the annual goals and objectives.
Findings:
The policy did not document time frames for the listed goals and objectives.
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Plan of Correction
The facility director will revise the facility goals and objectives to more clearly identify time frames for completion and review. They will be resubmitted to the Board President for review and signature by 10/17/08.
The Director will review and ensure that there are establish time frames for goals and objectives annually to make sure this does not recur. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of thirteen client records on September 15-17, 2008, the facility failed to document that clients were informed of the right to appeal a decision limiting access to his/her records to the project director in 13 of 13 client records where required.
Findings:
The facility did not document that the clients were informed of this right in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13.
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Plan of Correction
The patient handbook has been revised to include this information. Staff will begin utilizing the new handbook no later than 10/17/08. The patients will continue to sign off that they have received a copy of the handbook.
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709.30(6) LICENSURE Client Rights
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of thirteen client records on September 15-17, 2008, the facility failed to document clients were informed of the right to submit rebuttal data or memoranda to his/her own records in 13 of 13 client records where required.
Findings:
The facility did not document that the clients were informed of this right in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13.
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Plan of Correction
The patient handbook has been revised to include this information. Staff will begin utilizing the new handbook no later than 10/17/08. The patients will continue to sign off that they have received a copy of the handbook.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of thirteen client records on September 15-17, 2008 , two were reviewed as in patient non hospital short-term detoxification. The facility failed to document a psychosocial evaluation in one of one client record where required.
Findings:
The facility did not document a psychosocial evaluation in client record #1.
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Plan of Correction
The Director of Nursing will send a memo to all nursing staff no later than 10/15/08 reminding them of the time frames for the psychosocial evaluation and the need to complete them on all patients. The nurses will be expected to sign off on the memo acknowledging that they have received and understand the memo. The intake summary form will be revised no later than 10/21/08 to include a check mark acknowledging that the psychosocial evaluation has been completed. |
709.64(c)(1) LICENSURE Medical/dental support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on the review of administrative documentation on September 15-17, 2008, the facility failed to document that clients were assisted in obtaining supportive services for dental care.
Findings:
The facility did not provide documentation that dental services were available to clients.
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Plan of Correction
A local dental facility has verbally agreed to sign a letter of agreement with this facility to see our patients in need of dental care. The official letter of agreement was mailed out for signatures 10/9/08. If the signed letter is not returned by 10/16/08 a follow up call will be made to obtain the signed letter. |
709.64(c)(3) LICENSURE Legal support service
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of administrative documentation on September 15-17, 2008, the facility failed to document that clients were assisted in obtaining supportive services for legal issues.
Findings:
The facility did not provide documentation that legal services were available to clients.
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Plan of Correction
The Director has attempted to have Legal Aid sign a letter of agreement but have not received any response to my requests. The Director will continue to attempt to enter into an agreement with them. In the meantime the Director will also contact some of the attorneys associated with the local Drug Court in an attempt to reach an agreement with them. If the Director is unable to resolve this issue by December 23, 2008 she will contact the department of licensing for further direction and guidance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of thirteen client records on September 15-17, 2008, five were reviewed as inpatient records. The facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in three of five client records where required.
Findings:
The facility did not document group notes in compliance with the number of groups clients were to attend weekly as documented on the treatment plan in client records # 3, 4 and 5.
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Plan of Correction
Director of Residential Services has already met with the counselors to inform them that a progress note needs to be completed on all patients in the treatment group on a daily basis. This will provide proof that they have attended the required number of sessions, in addition to the documentation on the record of service. They have already begun the process of doing this. The Director of Residential Services will complete random chart audits( a minimum of 2 per counselor per month) on a monthly basis and include them in her monthly report, beginning with October's monthly report to confirm that this is being completed. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on the review of administrative documentation on September 15-17, 2008, the facility failed to document that clients were assisted in obtaining supportive services for dental care.
Findings:
The facility did not provide documentation that dental services were available to clients.
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Plan of Correction
A local dental facility has verbally agreed to sign a letter of agreement with this facility to see our patients in need of dental care. The official letter of agreement was mailed out for signatures 10/9/08. If the signed letter is not returned by 10/16/08 a follow up call will be made to obtain the signed letter. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of administrative documentation on September 15-17, 2008, the facility failed to document that clients were assisted in obtaining supportive services for legal issues.
Findings:
The facility did not provide documentation that legal services were available to clients.
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Plan of Correction
The Director has attempted to have Legal Aid sign a letter of agreement but have not received any response to my requests. The Director will continue to attempt to enter into an agreement with them. In the meantime the Director will also contact some of the attorneys associated with the local Drug Court in an attempt to reach an agreement with them. If the Director is unable to resolve this issue by December 23, 2008 she will contact the department of licensing for further direction and guidance. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on the review of thirteen client records on September 15-17, 2008, five were reviewed as inpatient records. The facility failed to document complete progress notes in three of five client records where required.
Findings:
The facility documentation of group notes was not consistent with the record of service log in client records # 3, 4 and 5.
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Plan of Correction
Director of Residential Services has already met with the counselors to inform them that a progress note needs to be completed on all patients in the treatment group on a daily basis. They have already begun the process of doing this. The Director of Residential Services will complete random chart audits( a minimum of 2 per counselor per month) on a monthly basis and include them in her monthly report, beginning with October's monthly report to confirm that this is being completed. |
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
Based on the review of thirteen client records on September 15-17, 2008, six were reviewed as outpatient records. The facility failed to develop an individual treatment and rehabilitation plan with the client according to facility policy and procedure in two of five client records where required.
Findings:
The treatment plans were not completed within the facility's stipulated time frame in client records # 8 and 10.
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Plan of Correction
The Director of Outpatient Services will circulate a memo no later than 10/17/08 reminding staff of the time frames for treatment plan completion.
Each counselor will sign off acknowledgement that they have reviewed the memo no later than 10/21/08.
The Director of OP services will utilize secretarial staff in OP offices to assist with monitoring paperwork completion checklists to ensure that treatment plans are being completed within the time frames and they will alert her if things are not being completed as required.This will be in place by 10/21/08 |