INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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
The facility failed to obtain an informed and voluntary consent from the client in one of seven client records.
Client # 1 was admitted on July 27, 2020 and was still an active client at the time of the inspection. A letter was sent to a judge on December 4, 2020. There was no documentation of a release of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning in March 2021, consents are completed within the Electronic Health Record. The consents will continue to be submitted into EHR.
Effective immediately, Program supervisors will re-educate staff regarding 709.28 Confidentiality regulation on obtaining a consent to release protected health information of client and completing the Release of Information accurately. All patients will sign a consent to release protected health information prior to releasing PHI, effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have a current and completed Release of Information on file. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client, that the client was notified that no client may be deprived of a civil right solely by reason of treatment in seven of seven client records.
Client records # 1, 2, 3, 4, 5, 6 and 7 did not document notification of this right.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure all components of the Client Rights are included in the Client Rights signature page.
Effective immediately, program supervisors will re-educate staff regarding 709.30 Client Rights statement and regulations, including the, and Client Rights signature page.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Client's rights will be signed by all patients at their next session, effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client that the client was notified of the right that the project may not discriminate in the provision of services on the basis of age, ethnicity, natural origin, marital status, sexual orientation and handicap or religion in seven of seven client records.
Client records # 1, 2, 3, 4, 5, 6 and 7 did not document notification of these rights.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure all components (The project may not discriminate in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion) of the Client Rights are included in the Client Rights signature page.
Effective immediately, program supervisors will re-educate staff regarding 709.30 Client Rights statement and regulations, including the policies and procedures, and not discriminating in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Client's rights will be signed by all patients at their next session effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client that the client was notified that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. This was found in seven of seven client records.
Client records # 1, 2, 3, 4, 5, 6 and 7 did not document notification of this right.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure it includes: clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Effective immediately, program supervisors re-educated staff regarding 709.30 (5) client rights; clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Staff will inform clients of their right to request their records to be corrected as it pertains to 709.30 (5). Client's rights will be signed by all patients at their next session effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by the client that the client was notified that the client has the right to submit memoranda to their own records in seven of seven client records.
Client records # 1, 2, 3, 4, 5, 6 and 7 did not document notification of this right.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 22, 2021, program supervisors revised the Client Rights statement to ensure it includes: clients have the right to submit rebuttal data or memoranda to their records.
Effective immediately, program supervisors re-educated staff regarding 709.30 (6) client rights; clients have the right to submit rebuttal data or memoranda to their records.
Effective immediately, staff will roll out the updated client rights for patients as they arrive for services, obtain an updated signature for client rights, and ensure the document is placed in client's records. Staff will inform clients of their right to clients have the right to submit rebuttal data or memoranda to their records as it pertains to 709.30 (6). Client's rights will be signed by all patients at their next session effective May 1, 2021.
As of May 1, 2021, monthly chart audits will be conducted to ensure clients have an updated client rights signature page reflecting the changes. Program supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor.
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