INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13-14, 2024 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of detoxification client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in three out of four applicable client records reviewed.
Per the requirement in the DDAP Licensing Alert 02-21 the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice
Client # 3 was admitted to the inpatient non-hospital detoxification activity on June 19, 2024, and was discharged against medical advice on June 26, 2024. There was no documentation that the emergency contact was notified of the clien'ts discharge from the facility against medical advice as of the date of the inspection.
Client #6 was admitted to the inpatient non-hospital detoxification activity on May 20, 2024 and was discharged against medical advice on May 24, 2024. There was no documentation that the emergency contact was notified of the client's discharge from the facility against medical advice as of the date of the inspection.
Client #7 was admitted to the inpatient non-hospital detoxification activity on March 6, 2024 and was discharged against medical advice on March 8, 2024. There was no documentation that the emergency contact was notified of the client's discharge from the facility against medical advice as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the licensing inspection on August 12, 2022 and August 18, 2023.
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Plan of Correction
Per receiving a violation, in the past two consecutive years, for not documenting a contact with next of kin when someone leaves unplanned, the following plan of correction will be implemented.
· There is a revision to the Twin Lakes entitled workflow "Documentation of an Unplanned Discharge NOK (Next of Kin) Notification".
· A tutorial has been built and attached to workflow for staff to follow on submitting documentation in our EHR for NOK notification
· All staff will be notified of the change to the guideline via email & communicated verbally, during daily huddles no later than 10/4/24. This communication with all staff will be completed by supervisors.
· Twin Lakes program supervisors will perform a reeducation with staff on the necessity of completing a collateral note, in the EHR, when NOK is contacted for unplanned discharges per the 709.24 (a) (3) regulation, unless the consent is revoked by the client.
The staff being educated will place their signature on a sign off sheet acknowledging their understanding of the updated guideline. This will be completed by 10/4/2024
· Twin Lakes program supervisors made a revision to the "Unplanned Discharge Case Consult" form, which now includes a signature line for a secondary staff to "witness" that a collateral note has been entered, in the EHR, by the staff managing the unplanned discharge that is to be done as part of the unplanned discharge process when the client is leaving the facility. This form will be reviewed by Supervisors with all staff and signed off on by staff no later than 10/4/24. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for contacting a client's emergency contact within twelve hours of a client leaving against medical advice was submitted and approved for the August 18, 2023 and August 12, 2022 annual licensing inspections. This deficiency was again found during this licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Per receiving a violation, in the past two consecutive years, for not documenting a contact with next of kin when someone leaves unplanned, the following plan of correction will be implemented.
· There is a revision to the Twin Lakes entitled workflow "Documentation of an Unplanned Discharge NOK (Next of Kin) Notification".
· A tutorial has been built and attached to workflow for staff to follow on submitting documentation in our EHR for NOK notification
· All staff will be notified of the change to the guideline via email & communicated verbally, during daily huddles no later than 10/4/24. This communication with all staff will be completed by supervisors.
· Twin Lakes program supervisors will perform a reeducation with staff on the necessity of completing a collateral note, in the EHR, when NOK is contacted for unplanned discharges per the 709.24 (a) (3) regulation, unless the consent is revoked by the client.
The staff being educated will place their signature on a sign off sheet acknowledging their understanding of the updated guideline. This will be completed by 10/4/2024
· Twin Lakes program supervisors made a revision to the "Unplanned Discharge Case Consult" form, which now includes a signature line for a secondary staff to "witness" that a collateral note has been entered, in the EHR, by the staff managing the unplanned discharge that is to be done as part of the unplanned discharge process when the client is leaving the facility. This form will be reviewed by Supervisors with all staff and signed off on by staff no later than 10/4/24. |