INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 8-12, 2022 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
|
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on one of one applicable employee personnel records reviewed, the facility failed to provide documentation of at least 12 clock hours of annual training required for a clinical supervisor for the training year January-December 2021.
Employee # 2 was hired as a clinical supervisor on December 20, 2020 and was still in this position at the time of the inspection. After a review of employee #2 ' s personnel record, there was only 5 training hours documented.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 9/1/2022, clinical supervisor has all of the 12 clock hours of training completed. Upon hiring new clinical supervisors, Director, Clinical Care Services will educate and ensure the supervisor meets the regulatory requirements of 12 training hours annually. Director will review on a quarterly basis the training hours for clinical supervisor. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on one of five applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2021.
Employee # 5 was hired as a counselor on October 1, 2020 and was still in this position at the time of the inspection. After a review of employee #5 ' s personnel record, there was only 15.5 training hours documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 11, 2021 annual licensing inspection.
|
Plan of Correction
Upon hiring new clinical counselors, the program supervisor will educate and ensure the counselor meets the regulatory requirements of 25 training hours annually. Supervisor will review on a quarterly basis the training hours completed for counselors. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Cameras are located in the small group room and the cafeteria where groups are also held.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Maintenance Supervisor will remove the cameras in the group rooms by September 15, 2022. A before and after picture will be provided to auditor. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on the review of the facility's fire drill log for the months of July 2021 through June 2022, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was only one overnight fire drill documented on September 13, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/12/22, Maintenance Supervisor sent an email was to staff who conduct fire drills to "rotate exits and rotate times of the day when doing the fire drills". On 8/18/22, the fire drill tracking sheet was updated, and Maintenance Supervisor will keep track of all drills to ensure the drills meet the 705.10(d)(5) regulatory requirements. *copy of the log sent to DDAP auditor. |
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.
|
Observations
Based on one of three applicable client records reviewed, the facility failed to provide documentation of the emergency contact in accordance to the facility policy and procedure manual.
Client # 11 was admitted on July 13, 2022 and was discharged July 21, 2022. Client # 11 left the facility against medical advice and the emergency contact identified in the client record was not notified.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Twin Lakes Director will review current guidelines and make revisions to ensure there are written procedures to include emergency contact notification, process for clients leaving AMA, and adherence of staff following Twin Lakes guideline.
By 9/30/2022, All staff will be notified of this change via e-mail and verbally in a daily huddle. |
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 one 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 specific information disclosed be limited to what the informed and voluntary consent form allowed.
Client # 6 was admitted on June 28, 2022 and was still active at the time of the inspection. Informational notes documented discussions with "other treatment facilities and halfway houses" that included medically assisted treatment information that was not included on the informed and voluntary consent from the client for the disclosure of information allowed by the client. Informed and voluntary consent forms allowed for the release of: Whether the client is or is not in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client, and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 11, 2021 and April 7, 2021 annual licensing inspection.
|
Plan of Correction
Twin Lakes Director will provide training to staff regarding 709.28(c)(2) requirement to obtain an informed and voluntary consent from clients for disclosure of specific information contained in client record to be released.
All clinical and administrative staff will be trained by 10/31/2022. Supervisors will review client charts monthly to ensure consents are completed in it's entirety along with the specific information disclosed. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
|
Observations
Based on two of four 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 indicates a follow-up to the client occur within 7 days by letter.
Client # 3 was admitted on June 27, 2022 and discharged on June 30, 2022. There was no follow-up information documented in the client record.
Client # 4 was admitted on June 24, 2022 and discharged on June 28, 2022. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Residential Supervisor met with the individual responsible for post-discharge calls on July 13, 2022, to review these protocols. The residential supervisor will monitor ongoing compliance in supervision as needed.
|
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on one of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7 days of discharge.
Client # 10 was admitted on July 5, 2022 and was discharged on July 13, 2022. The discharge summary was due to be completed no later than July 20, 2022 however, the discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
OP Nurse Coordinator will meet with all Detox staff to review discharge protocols no later than September 16, 2022. For individuals who are leaving Detox without stepping down to residential treatment, the nurse completing the Discharge ASAM will be responsible to complete the Discharge summary. The OP Nurse coordinator will monitor monthly chart audits to ensure compliance. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
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 # 9 was admitted on May 6, 2022 and discharged on May 26, 2022. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 11, 2021 annual licensing inspection.
|
Plan of Correction
Residential Supervisor met with the individual responsible for post-discharge calls on July 13, 2022, to review regulatory requirements. The residential supervisor will monitor ongoing compliance in supervision monthly. |