INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on January 26, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Centers PA-VIL,LLC d/b/a Hanover Treatment Services 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #5 and #6 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #5 was hired as a counselor on June 1, 2020 and was still in this position at the time of the inspection. Employee # 5 was due to have the communicable disease trainings no later than June 1, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #6 was hired as a counselor on November 23, 2020 and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than November 23, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed the DDAP training policies and procedures with all employees on 2.1.22 during the review of DDAP citations meeting. Employee #6 has registered for the HIV/AIDS training and will attend on February 17 and 18, 2022. Employee #5 will provide the training certificate once the training has been completed to ensure an audit of the corrective action and completion of the training. Employee #5 continues to search for open HIV/AIDS and TB/STD trainings available on TMS training website. Employee #5 will register for both trainings as soon as they are available. Employee #5 will provide a confirmation email when they have registered for the trainings and provide a completion certificate to ensure an audit of the corrective action has been completed and completion of the training has occurred. Clinical Supervisor will track DDAP trainings for each counselor via spreadsheet to ensure that all staff obtain the required trainings within their first year of hire. This will be reviewed with staff in weekly/monthly supervision. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on one 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 to include documentation of whether a copy of the consent was offered to the client.Client # 7 was admitted on May 5, 2021 and discharged on September 21, 2021. Eight informed and voluntary consent from the client for the disclosure of information in the client record did not include documentation of whether a copy of the consent was offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed the development of release of information and the identified necessary parts that must be completed to be a valid release of information 709.28 Plan of Correction: Executive Director reviewed the development of release of information and the identified necessary parts that must be completed to be a valid release of information on 2/1/22 during the all staff meeting to review DDAP citations. Clinical Supervisor will conduct Intake Chart Audits within 7 days of intake to ensure that all releases of information we completed accurrately and thoroughly. Executive Director and Clinical Supervisor will conduct monthly chart audits and review all releases of information to ensure they are all completed accurately and thoroughly. The weekly and monthly audits will assist in assuring that the corrective action and training is being implemented and releases of information are being generated correctly.
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on three of seven client records reviewed, the facility failed to document written authentication for verbal orders for medication by the physician within three business days from the time the order was given.Client # 3 was admitted on October 25, 2021 and was still active at the time of the inspection. A verbal order was given for a dose increase on November 8, 2021 from 55mg to 65mg, November 4, 2021 from 50mg to 55mg, and November 1, 2021 from 40mg to 50mg. Written authentication was not given by the physician until December 16, 2021.Client # 4 was admitted on June 23, 2021 and was still active at the time of the inspection. A verbal order was given for a dose increase on November 1, 2021 from 50mg to 60mg. Written authentication was not given by the physician until December 16, 2021.Client # 7 was admitted on May 5, 2021 and was discharged on September 21, 2021. A verbal order was given for a dose decrease on May 21, 2021 from 40mg to 30mg. Written authentication was not given by the physician until May 27, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with Medical Director on 2.2.22 regarding the regulations related to verbal orders. Executive Director reviewed with Medical Director that verbal orders must be signed within 3 business days and was advised to review the necessary documents that are in need of his signature daily in the EMR. Clinical Supervisor will conduct Intake Chart Audits within 7 days of intake to ensure that all verbal orders have been signed within 3 business days. Executive Director and Clinical Supervisor will conduct monthly chart audits and review verbal orders to ensure they are being signed within 3 business days. The weekly and monthly audits will assist in assuring that the corrective action and training is being implemented and verbal orders are being signed within 3 business days. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on one of one applicable client records reviewed, the facility failed to provide documentation of written notification to the client the decision to involuntarily terminate the client's treatment and the reason for the termination.Client # 6 was admitted on January 26, 2021 and administratively discharged on December 19, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with all staff on 2.1.22 to review DDAP citations and provide training on the documentation of written notification to the client that is necessary when the decision is made to involuntarily terminate the client's treatment. Executive Director met with CRNP on 2.1.22 and Medical Director on 2.2.22 to review the document necessary to review with the patient when they are being involuntarily terminated. Executive Director and Clinical Supervisor will conduct monthly chart audits and review involuntary tapers to ensure that the documentation for withdrawal from Methadone has been completed, reviewed, and signed by the patient. Clinical supervisor will conduct weekly audits for any patient who has been placed on an involuntary taper to ensure that the written documentation for withdrawal from Methadone has been completed, reviewed, and signed by the patient. The audits will ensure that the corrective action is being implemented and the required documentation is being completed. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on four of seven patient records reviewed, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy in patient records # 1,3,5,7.Patient # 1 was admitted on February 27, 2020 and was still active at the time of the inspection. A review of progress notes indicated 2.5 hours of psychotherapy were not provided the months of May, June, July, August, September, October, November, and December 2021.Patient # 3 was admitted on October 25, 2021 and was still active at the time of the inspection. A review of progress notes indicated 2.5 hours of psychotherapy were not provided the months of October 25-November 25, November 26-December 25, and December 26, 2021 and January 25 2022.Patient # 5 was admitted on September 28, 2021 and was discharged on November 4, 2021. A review of progress notes indicated 2.5 hours of psychotherapy were not provided the months of September 28-October 28, 2021..Patient # 7 was admitted on May 5, 2021 and was discharged on September 21, 2021. A review of progress notes indicated 2.5 hours of psychotherapy were not provided the months of May 5- June 5, June 6-July 5, and July 6-August 5, 2021.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 18, 2021 annual licensing inspection.
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Plan of Correction
Executive Director held an all staff meeting on 2.1.22 to review DDAP citations. Executive Director provided re-training on managing caseloads to ensure that patients are receiving their required psychotherapy services as well as continuously documenting when patients do not attend group or individual sessions and attempts to re-engage into treatment. Executive Director and Clinical Supervisor will conduct monthly chart audits and review psychotherapy time to ensure that patients are receiving the required time in treatment. Executive Director will monitor the Monthly Requirements report from the EMR weekly to ensure that counselors are able to successfully manage their caseloads and ensure that the corrective action is implemented and patients are receiving their required psychotherapy time and/or there is copious documentation related to missed sessions and attempts to re-engage. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on one of one applicable patient records reviewed, the facility failed to provide a complete patient record to include all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in patient record # 1.Patient # 1 was admitted on February 27, 2020 and was still active at the time of the inspection. The annual physical documented in the patient record did not occur until October 14, 2021 but was due no later than February 27, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director held an all staff meeting on 2.1.22 to review DDAP citations. All staff training was provided on managing caseloads and caseload documentation to ensure that annual physicals are scheduled and completed on or prior to the due date. Executive Director provided training to front desk staff to ensure they are aware of the procedures when assisting to schedule annual physicals so they are completed on time or prior to the due date. Executive Director and Clinical Supervisor will conduct monthly chart audits and review patient charts for annual physical documentation and completion on or prior to the due date. The monthly audits will assist in assuring that the corrective action and training is being implemented and annual physicals and documentation of such are being completed on or prior to the due date and that the corrective action is being implemented. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on one of two applicable patient records reviewed, the facility failed to provide a complete patient record to include an annual evaluation of each patient 's status being completed by the patient's counselor and being reviewed, dated, and signed by the medical director in patient record # 1.Patient # 1 was admitted on February 27, 2020 and was still active at the time of the inspection. The annual evaluation was due no later than February 27, 2021. There was no documentation of an annual evaluation in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director held an all staff meeting on 2.1.22 to review DDAP citations. All staff training was provided on managing caseloads and caseload documentation to ensure that annual clinical evaluations are scheduled and completed on or prior to the due date. Executive Director and Clinical Supervisor will conduct monthly chart audits and review patient charts for annual clinical evaluation documentation and completion on or prior to the due date. The monthly audits will assist in assuring that the corrective action and training is being implemented and annual clinical evaluations and documentation of such are being completed on or prior to the due date and that the corrective action is being implemented. |
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 two of three applicable 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 the first follow-up to the client will occur within seven days of discharge and the second within 30 days.Client # 6 was admitted on January 26, 2021 and discharged on December 19, 2021. The first follow-up did not occur until January 20, 2022.Client # 7 was admitted on May 5, 2021 and discharged on September 21, 2021. The first follow-up did not occur until October 24, 2021 and the second follow-up occurred November 17, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director held an all staff meeting on 2.1.22 to review DDAP citations. COE Case Management staff were re-trained on follow up calls and the facility policy and procedures and that follow-ups to occur within 7 days of discharge and 30 days post discharge. Executive Director and Clinical Supervisor will conduct monthly chart audits and review patient charts for patient follow up call documentation and completion on or prior to the due date. The monthly audits will assist in assuring that the corrective action and training is being implemented and patient follow up calls and documentation of such, are being completed on or prior to the due date and that the corrective action is being implemented. |