INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on September 9 - 11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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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 document an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of fourteen client records reviewed on September 9 - 11, 2019.
Client # 10 was admitted September 1, 2018 and discharged on September 5, 2018. The facility disclosed the name and diagnosis of client # 10 to the funding entity on September 3, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The evening staff that put charts together will review all agencies that involved with the client and inform the Residential Supervisor within 24 hours of any missed consents. Those consents will then be completed within 48hours
The Residential Supervisor and Administrative Assistant will monitor this with monthly chart audits and will address staff that misses consents consistently by re-educating them on the importance of completing a accurate consent. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to provide documentation that written unusual incident reports were filed with the Department within 3 business days of an event at the facility requiring the presence of ambulance personnel based on a review of unusual incident reports on September 11, 2019.
Events at the facility requiring the presence of an ambulance occurred on April 2, 2018 and November 23, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was addressed, the correct email address was added to the policy on 9/20/19 Manager of Residential Services updated the policy.
All supervisors will submit the incident form and a copy of their email with the correct address for verification the report was sent to the Executive Director within 24 hours of the incident.
All unusual incidents will be reported within required timeframes to DDAP. |