INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 12-13, 2013 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.
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Plan of Correction
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that exits from the residential facility were unobstructed.
The findings include:
A physical plant inspection was conducted on August 13, 2013. An exit door adjacent to a women's detox room could not be completely opened as it was obstructed by a damaged overhang that was sagging.
The Project/Facility Director was present during the physical plant inspection and confirmed the findings.
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Plan of Correction
The M/S/H supervisor fixed the door to the women's detox room that was obstructed to ensure that it is accessible immediately following the inspection on 8/16/13. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of the annual report, the facility failed to make available to the public an annual report which included a financial statement of income and a statement disclosing the names of the officers, directors and principal shareholders, where applicable.
The findings include:
The 2012 Annual Report was reviewed on August 12, 2013. The annual report did not document a financial statement of income or a statement disclosing the names of the officers, directors and principal shareholders, where applicable.
The Project/Facility Director was interviewed on August 12, 2013 and confirmed the findings.
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Plan of Correction
The Executive Director will change the current annual report to add the revenue and expense year end numbers as well as the list of Board of Directors by 9/13/13. Each year thereafter, the Executive Director will ensure to include the items of income and expense numbers and Board of Directors listing. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to secure discharged client records within locked storage containers.
The findings include:
A physical plant inspection was completed on August 13, 2013. Discharged client records were located on open shelves in a locked basement room. Although the room was locked, maintenance workers have items stored in the room. The maintenance workers have keys to the locked door and were observed entering and exiting the room. The maintenance workers have complete access to discharged client records.
The Project/Facility Director was present during the physical plant inspection and confirmed the findings.
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Plan of Correction
The M/S/H supervisor will construct a wall with a door between the charts and the storage that will eliminate M/S/H staff access to the clinical records effective 9/30/13. M/S/H staff needing to access the storage room will access it using the outside door which is locked from the clinical charts making them not accessible to any staff outside of the medical records staff. The M/S/H supervisor will notify the ED when this task is completed. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to ensure that staff physicians signed verbal medication orders in each client record within 24 hours as required by this regulation in two of six client records.
The findings included:
Eleven client records were reviewed on August 12-13, 2013. Six client records reviewed documented verbal medication orders. The facility did not document that the verbal medication orders were signed within 24 hours thereafter by the prescribing physician in client records # 2 and 4.
Client # 2 was admitted on July 19, 2013. A verbal medication order was documented as received by nursing staff on July 19, 2013. The prescribing physician's signature was dated as July 22, 2013.
Client # 4 was admitted on January 31, 2013. A verbal medication order was documented as received by nursing staff on January 31, 2013. The prescribing physician's signature was dated as February 4, 2013.
The Project/Facility Director was interviewed on August 12, 2012 and did not dispute the findings.
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Plan of Correction
Beginning on 9/6/13, the Director of Nursing will review patient charts to ensure that verbal orders are signed by the doctor within 24 hours. The Director of Nursing will also notify all nursing staff and the doctor to ensure that everyone is aware of the timeframe of 24 hours in the regulations and to understand the importance of compliance by 9/6/13. |