INITIAL COMMENTS
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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:
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility fire drill log for the months of July 2021 through June 2022, the facility failed to conduct a fire drill on different days of the week, at different times of the day and on different staffing shifts. Fire drills in February, March, April, May, and June 2022 were all conducted between the hour of 7 am and 8 am.
These findings were reviewed with facility staff during the licensing process.
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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 regulatory requirements.
Copy of email and tracking sheet sent to auditor 9/07/2022 |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on three of five applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 3, 4, and 5.
Client # 3 was admitted on May 11, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 1, 2022. A treatment and rehabilitation plan update was due no later than August 1, 2022 however, there was no documentation of a treatment plan update in the client record.
Client # 4 was admitted on April 20, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 11, 2022. A treatment and rehabilitation plan update was due no later than July 1, 2022 however, a treatment and rehabilitation plan update did not occur until July 11, 2022.
Client # 5 was admitted on November 29, 2021 and was discharged on July 1, 2022. A treatment and rehabilitation plan update was developed on April 7, 2022. A treatment and rehabilitation plan update was due no later than June 7, 2022 however, there was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisors will re-educate clinical staff on Twin Lakes workflow and 709.92 regulatory requirements to complete individual treatment plans, by September 30, 2022.
Beginning September 2022, Operations team will be generating a monthly Treatment Plan Report and supervisors are responsible for analyzing and ensuring that all patients have a current valid TXP.
Client #3, #5 have been discharged and client #4 TXP completed and valid.
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