INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26-27, 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, Pinnacle Treatment Centers LLC, d/b/a Hanover Treatment Center 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on review of personnel records conducted on February 26-27, 2019, it was discovered that a counselor, hired on January 7, 2019, did not have at least one year of experience as a counselor. Employee # 5 was hired on January 7, 2019 and was still in this position at the time of the inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselor hired on 1/7/19 employment status has changed to Counselor Assistant. Counselor Assistant will and is receiving documented weekly supervision by Lead Counselor. Counselor Assistant will receive 90 day evaluation, administered by Executive Director, along with semi-annual evaluation. Counselor Assistant will be evaluated at semi-annual evaluation by the Executive Director and Lead Counselor to determine promotion to Counselor. Weekly supervision by Lead Counselor had begun the week of 2/11/19 and will continue for 1 year. To ensure that this does not occur again, Executive Director will review all resumes to ensure that clinical experience, such as facilitation of individual session, group sessions, and creation and review of treatment plans is documented in candidate's application and resume. HR will also vet all incoming candidates through our application system to ensure that they meet DDAP 704.7 regulations. Facility will be in compliance as of 2/28/19. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
During an onsite licensing inspection conducted on February 26-27, 2019, the facility failed to document physician services for at least 1 hour per week onsite for 10 patients.The week of December 23-29, 2018 17.8 hours were required for a patient census of 178. The facility only documented 16.22 hours of onsite hours.The week of December 30-January 5, 2019 17.6 hours were required for a patient census of 176. The facility only documented 11.65 hours of onsite hours.The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director conducted a meeting with Physician on 3/5/19 to determine a plan for Physician's time off moving forward. Executive Director and Physician determined that Physician will find alternative work days to provide physician services (1 hour per week onsite for 10 patients) during the weeks he would be out of the office. To ensure that we meet the required physician time per week, the doctor will provide required Physician staffing hours on an otherwise alternative day during the week which would complement his time off. Facility will be in compliance as of 3/5/19 at completion of the meeting between ED and Facility Medical Director. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
During an onsite inspection conducted February 26-27, 2019, the facility failed to document time provided by a physician assistant or certified registered nurse practitioner did not exceed two-thirds of the required narcotic treatment physician time.The week of December 23-29, 2018 of the 17.8 required hours, the CRNP documented 11.65 hours which exceeded the allowed 4 hours. The week of December 30-January 5, 2019 of the 17.6 required hours, the CRNP documented 11.65 hours which exceeded the allowed 5 hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Please refer to POC 715.6(e). To ensure that that required physician hours are met each week, the doctor will provide required Physician staffing hours on an alternative day during the week which would complement his time off. Nurse Practitioner will not be utilized in place of doctor's hours and will only provide two-thirds of the required narcotic treatment physician time. Executive Director will meet with the physician to determine an alternative day for services upon notification of the physician needing scheduled time off. Facility will be in compliance as of 3/5/19 at completion of the meeting between ED and Facility Medical Director. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
During an onsite inspection conducted February 26-27, 2019, the facility failed to provide documentation verifying the age and identity of client # 11.Client # 11 was admitted on March 29, 2017 and was discharged on November 2, 2018. There was not record of identifying documentation in the client record. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct an All-Staff meeting on 3/13/19 which will ensure completion of weekly record reviews, which will allow staff to ensure that identifying documentation are in the clinical record. Supervision was held with Front Desk Receptionist on 3/5/19 (as copying and charting identifying documentation is a part of their job responsibilities) to ensure use of intake checklist, which provides documentation of identifying documentation. To ensure that documentation of the client's age and identity is found in the chart, weekly chart audits will be completed by the clinician. Those audits will be turned into the Lead Counselor, who will then review the chart audits and ensure that all corrections needed are made. Executive Director will audit those findings monthly and record all findings and corrections made on a monthly basis. QI will conduct a quarterly site and chart audit visit to also ensure that all required documentation is found in the charts. Facility will be in compliance upon completion of the all-staff meeting on 3/13/19. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on an onsite inspection conducted on February 26-27, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 section 709.28 (c) (1) for releases of information in patient record #'s 10, 12, and 14.Patient # 8 was admitted on May 22, 2018 and was still an active patient at the time of the inspection. There was a consent to release form signed and dated on May 22, 2018 that did not provide the name of the person, agency or organization to whom disclosure was to be made. Patient # 9 was admitted on October 12, 2017 and was still an active patient at the time of the inspection. There was a consent to release form signed and dated on October 12, 2017 that did not provide the name of the person, agency or organization to whom disclosure was to be made. Patient # 10 was admitted on September 12, 2018 and discharged on January 31, 2019. There was a consent to release form signed and dated on January 31, 2019 that did not provide the name of the person, agency or organization to whom disclosure was to be made. Patient # 12 was admitted on February 27, 2018 and discharged on October 10, 2018. There was a consent to release form signed and dated on October 10, 2018 that did not provide the name of the person, agency or organization to whom disclosure was to be made. Patient # 14 was admitted on August 15, 2018 and was still an active client at the time of the inspection. There was a consent to release form signed and dated on August 15, 2017 that did not provide the name of the person, agency or organization to whom disclosure was to be made. The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
QI and Pinnacle Legal Department will review Dual Enrollment Admission form and Release Authorization and make the necessary changes to the Release Authorization to ensure that person, agency, or organization to whom disclosure was to be made will be added to the Dual Enrollment Release Authorization. This will be completed by May 31, 2019, therefore the facility will be in compliance as of 5/31/19. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
During an onsite inspection conducted February 26-27, 2019, the facility failed to provide documentation that transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient were provided to the receiving facility. Patient # 11 was admitted on March 29, 2017 and was discharged on November 2, 2018. There was documentation in the patient record of being transferred to another facility but not documentation of information the patient file being transferred to the facility. The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct an All-Staff meeting on 3/13/19 to educate staff on the process of patient transfers and that all documentation send to receiving clinic is required to be scanned into client chart. Staff will also be educated on the use of the transfer in and transfer out checklists to help ensure that all documentation sent from the program is scanned into the chart. All Transfer in and Transfer out requests will be reviewed by Lead Counselor to ensure that all documentation has been provided and that all information has been scanned into the chart, thus ensuring that this does not occur again. Facility will be in compliance upon completion of the all-staff meeting on 3/13/19. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
During an onsite inspection conducted on February 26-27, 2019, the facility failed to provide documentation of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in patient record #11. The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct an All-Staff meeting on 3/13/19 to educate staff on the process of patient transfers and that the transfer verification form which documents the admission and dose given to the patient by the receiving narcotic treatment program must be scanned in the patient's chart, as well as documented via case management note in the chart. To ensure that documentation of the client's admission to the program transferred, as well as the date of the initial dose at the clinic transferred to is found in the chart, weekly chart audits will be completed by the clinician. Those audits will be turned into the Lead Counselor, who will then review the chart audits and ensure that all corrections needed are made. Executive Director will audit those findings monthly and record all findings and corrections made on a monthly basis. QI will conduct a quarterly site and chart audit visit to also ensure that all required documentation is found in the charts. Facility will be in compliance upon completion of the all-staff meeting on 3/13/19. |
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
During an onsite inspection conducted on February 26-27, 2019, the facility failed to document the results of an annual physical exam to include an annual reevaluation by the narcotic treatment physician in patient record #14.Patient # 14 was admitted on August 15, 2017 and was still an active patient at the time of the inspection. An initial exam was conducted on August 15, 2017 with an annual reevaluation being due August 15, 2018. Another exam was not completed until January 2, 2019.The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct an All-Staff meeting on 3/13/19 to educate staff on utilizing alerts and delays in patient charts as reminders to schedule all required physician services on time. Any patient reschedules or no-shows will be documented in the chart in the form of phone calls, treatment plans, and session notes. If a patient is found to not meet their annual requirements, the patient will meet with the Lead Counselor and Executive Director to discuss barriers to these appointments as well as discuss the importance of these appointments. If necessary, Executive Director will place a Director Delay on patient until the patient completes their annual physical exam. All efforts and discussions will be documented in the patients chart. Facility will be in compliance upon completion of the all-staff meeting on 3/13/19. |
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
During an onsite inspection conducted on February 26-27, 2019, the facility failed to provide documentation of annual evaluation completed by the patient ' s counselor in patient record # 11.Patient # 11 was admitted on March 29, 2017 and was discharged on November 2, 2018. An annual evaluation was due on March 29, 2018The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct an All-Staff meeting on 3/13/19 to discuss weekly reviews of services due. Lead Counselor will review all services due in weekly supervisions to ensure completion of all clinical documentation on time, to ensure that annual physical exams are completed by the due date. Any patient reschedules or no-shows (if clinical documentation requires patient participation) will be documented in the chart in the form of phone calls, treatment plans, and session notes. Facility will be in compliance upon completion of the all-staff meeting on 3/13/19. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
During an onsite inspection conducted on February 26-27, 2019, the facility failed to provide documentation of a consent to treatment in 3 of 7 Outpatient drug-free records reviewed. Client # 2 was admitted on December 13, 2018 and was still an active client at the time of the inspection.Client # 3 was admitted on November 6, 2018 and was still an active client at the time of the inspection.Client # 7 was admitted on October 31, 2018 and was discharged on January 17, 2019.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct an All-Staff meeting on 3/13/19 to discuss intake and admission processes for MMT, OP, and OBOT intakes/admissions. An OBOT/OP/MMT intake/admission checklist was created and will be used by all staff when conducting an intake/admission to ensure that all documentation, including but not limited to, consent for treatment is found in all charts. To ensure that documentation of the client's consent for treatment is found in the chart, weekly chart audits will be completed by the clinician. Those audits will be turned into the Lead Counselor, who will then review the chart audits and ensure that all corrections needed are made. Executive Director will audit those findings monthly and record all findings and corrections made on a monthly basis. QI will conduct a quarterly site and chart audit visit to also ensure that all required documentation is found in the charts. Facility will be in compliance upon completion of the all-staff meeting on 3/13/19.
Executive Director will ensure that Client #2 has signed a Consent for Treatment in the client's chart by 4/3/19.
Executive Director will ensure that Client #3 has been discharged from treatment as he did not re-engage since last appointment in February. Client #3 was discharged on 3/1/19 therefore a Consent for Treatment will be unable to be obtained for this client. |