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) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of July 2021 through June 2022, the facility failed to prepare alternate exit routes to be used during fire drills. All fire drills were documented to have used the "Front door" for the fire drills.
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 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(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 two of five applicable client records reviewed, the facility failed to provide a comprehensive treatment plan within thirty days in accordance with the facility policy and procedure manual in client records # 2 and # 4.
Client # 2 was admitted on June 21, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than July 21, 2022 however, no comprehensive treatment plan was documented in the client record.
Client # 4 was admitted on May 3, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than June 3, 2022 however, the comprehensive treatment plan was documented in the client record until June 28, 2022.
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.
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