INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8-11, 2021 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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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on one of six personnel records reviewed, the facility failed to provide documentation of the required thirty clock training hours annually for a counselor assistant.
Employee # 5 was hired as a counselor assistant on April 10, 2018 and was still in this position at the time of the inspection. After a review of employee # 5's personnel record and training certificates, there was only twelve hours of trainings documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 15, 2021, supervisors added training hours to the supervision note in order to monitor training hours on all employees for the 2021 calendar year to ensure that all training hours are met. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the nurse schedule and census provided by the facility for the month of July 2021, the facility failed to provide at least one primary care staff person during primary care hours.
On July 10, 2021 the facility census showed two clients admitted and the staff scheduled indicated no coverage from 6 pm until 7 am, July 11, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of September 1, 2021, Supervisors will comply with client/staff and client/counselor ratios during primary care hours. Supervisors will also ensure that all staffing schedules are correct and updated as scheduling changes occur. After reviewing schedule, hours on the schedule given to auditor did not reflect changes that occurred for the month of July.
Outpatient Nurse Coordinator will create a final document demonstrating an accurate schedule of hours covered for the previous month by the 15th of each month. Effective 9/30/21.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. A shower in the female bathroom had a shower head and handle that was rusted and the walls surrounding the shower was peeling and molded. The floor in front of the shower was warn and had water damage to the extent that the floor was soft.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Twin Lakes Maintenance will complete:
- Repairs on the floor 9/17/21.
- Shower head and handle will be replaced by 9/17/21.
- Repairs on the wall surround will be completed by 9/24/21.
*maintenance staff will conduct monthly facility rounds to ensure the facility is clean, sanitary, and free from repairs and notify Director Clinical Care Services effective 9/30/21
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the project fiscal management, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the fiscal year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
WBH @ Twin Lakes will work with UPMC's financial auditor to ensure that the 2021 audit is completed in a timely manner. If the UPMC financial auditor informs the Director that the audit will be late, Director will request an exenstion to DDAP. Effective 9/1/2021. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on three of six personnel records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee.
Employee # 3 was hired on March 22, 2011 and promoted to current position on March 9, 2020. There was no performance evaluation provided for 2020.
Employee # 5 was hired on January 4, 2018 and promoted to current position on April 10, 2018. There was no performance evaluation provided for 2020.
Employee # 6 was hired on Feburary 3, 2020 and was still in this position at the time of the inspection. There was no performance evaluation provided for 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of January 1, 2021, WBH at Twin Lakes has adopted UPMC's performance review procedures, which are conducted online in HR Direct portal. Staff will electronically acknowledge the completion of their performance review and Twin Lakes will provide a copy of the acknowledgement by staff for DDAP licensure. Twin Lakes will monitor due dates for performance evaluations, effective 9/1/2021.
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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.
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Observations
Based on one of fourteen records reviewed, the facility failed to keep the specific information to be disclosed within the limits of what was allowed on the release of information signed by the client.
Client # 9 was admitted on April 1, 2021 and was discharged on April 29, 2021. A release of information for a family member was signed by the client that limited the information to be disclosed to the five points of 255.5: " whether the client is or is not in treatment, the progress of the client, the nature of the project, a brief description of the progress of the client, a short statement as to whether the client relapsed into drug or alcohol abuse and the frequency of such relapse". A progress note documented on April 19, 2021 indicated a family session occurred with a family member providing information beyond what the release of information allowed.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 7, 2021 annual inspection.
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Plan of Correction
Beginning June 1, 2021, UPMC WBH at Twin Lakes implemented a new double-check protocol related to releasing confidential information. The 6/4/21 release was one of the first using this new protocol. All staff involved in this incident will be re-educated, by supervisor, on this process by September 30, 2021.
UPMC WBH at Twin Lakes, Director Clinical Services will revise the ROI for family sessions by 9/15/2021. All staff will be educated, by supervisor, on the new form during staff meetings between 9/15/21 and 10/15/21.Target for completion is 10/15/21
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on two of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the dated signature of witness.
Client # 5 was admitted to detox on May 18, 2021 and transferred to residential care on May 21, 2021. An informed and voluntary consent from the client for the disclosure of information dated May 18, 2021 to an "other agency" did not have a witness signature.
Client # 14 was admitted on July 20, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated July 20, 2021 to an "other agency" did not have a witness signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning June 1, 2021, UPMC WBH at Twin lakes implemented a new double check protocol related to releasing confidential information, which includes obtaining a dated signature of witness to release information. Clinicians generate the informed consent with the client. The informed consent is given to the front office staff who review for completeness and accuracy prior to releasing the information. Two of these three citations reference release that occurred prior to implementation of this protocol.
All staff involved in this incident will be re-educated, by supervisor on this process throughout September staff meetings. To be completed by September 30, 2021
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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.
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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 # 10 was admitted on June 2, 2021 and discharged on July 2, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervisor added the 7-day Follow-up letter document to the verification checklist on 9/2/21. The Customer Care Associate reviews the checklist to ensure all components of the chart, including the follow-up letter, is present prior to closing the client chart. Supervisor educated CCA of the additional item added to checklist. Effective 9/15/21. |