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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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.
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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. |
709.28 (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
Based on two of seven 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 in client records # 4 and # 5.
Client # 4 was admitted on May 25, 2021 and was still active at the time of the inspection. A letter allowing admit and discharge information dated May 25, 2021 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
Client # 5 was admitted on April 23, 2021 and was discharged on July 21, 2021. A letter allowing admit and discharge information dated April 23, 2021 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 1, 2021, WBH at Twin Lakes implemented a double check system for all outgoing shared 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. These citations reference release that occurred prior to implementation of this protocol.
Monthly chart audits will continue to be conducted to ensure Release of Information on file states the name of the person, agency, or organization to whom disclosure is made. Beginning August 2021, Program Supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor. Effective 8/30/2021
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on three of seven client records reviewed and the facility policy and procedure manual, the facility failed to document a completed comprehensive treatment plan to include a client acknowledgement within thirty days of admission in accordance with the facility policy and procedure manual.
Client # 4 was admitted on May 25, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was not acknowledged by the client until July 7, 2021 but was due to be completed no later than June 25, 2021.
Client # 5 was admitted on April 23, 2021 and was discharged on July 21, 2021. The comprehensive treatment plan was not acknowledged by the client until June 9, 2021 but was due to be completed no later than May 23, 2021.
Client # 7 was admitted on April 27, 2021 and was discharged on June 18, 2021. The comprehensive treatment plan was not acknowledged by the client until June 9, 2021 but was due to be completed no later than May 27, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For 2 of these 5 clients there was a significant lag between the first and second appointments. Therefore, effective October 1, 2021, all clients with a lag of more than 15 days between their first and second treatment sessions, the counselor will complete a comprehensive treatment plan on the second visit.
For 3 out of 5 clients where treatment plans were not signed within 30 days. New intake clients will be added to the case consult section of the supervision note as a standing supervision item, effective 9/30/2021. Supervisors will review the timely completing of all initial paperwork, including the comprehensive treatment plan as part of regularly scheduled supervision.
Supervisors will review these protocols for completing comprehensive treatment plans at all staff meetings in September and obtain a signature that staff are aware of the changes, effective 9/30/21
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709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide a complete client record to include an aftercare plan in accordance with the facility policy and procedure manual for an aftercare to be completed upon a client ' s successful discharge.
Client # 5 was admitted on April 23, 2021 and was successfully discharged on July 21, 2021. There was not an aftercare plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For 1 of the 2 clients noted, the individual was discharged as unsuccessful. This was indicated on both the roster and in the electronic health record. We would appreciate the opportunity to assist the auditor identifying unsuccessful discharges at the time of the audit.
Monthly chart audits will continue to be conducted to ensure an aftercare plan is on file after a client's successful discharge. This workflow was in place prior to the audit. Beginning August 2021, Program Supervisors will review results of chart audits with staff during supervision, which will be documented and signed off by both staff and supervisor. Effective 8/30/2021 |
709.93(a)(11) LICENSURE Client records
709.93. 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 # 5 was admitted on April 23, 2021 and discharged on July 21, 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, are present prior to closing the client chart. Supervisor educated CCA of the additional item added to checklist. Effective 9/10/21. |