INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 6, 2018, and February 14, 2018, by staff from the Division of Drug and Alcohol 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facility's release of information form template conducted at the Department's Harrisburg Office, the facility did not obtain informed and voluntary consents for any of its patients. All consent to release information forms included the following statement: "If I revoke this authorization, I need to do so in writing and mail or hand deliver it to the HIPAA Privacy Officer of the Pinnacle Provider Entity named above, at the address set forth above." The facility failed to adhere to the requirements in the federal confidentiality regulations by requiring the patients to revoke the consent in writing.These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
QI team referred information to Corporate Legal and after review with corporate legal team the ROI template within the EMR was modified for more user friendly language in support of Federal, State & accreditation expectations. The new language states: "This authorization may be revoked by me at any time in writing and/or verbally, except to the extent the above-named Pinnacle Provider Entity has already acted in reliance on this authorization. Acting in reliance includes, but is not limited to, the provision of treatment services in reliance on a valid consent to disclose information to a third party payer. If not revoked by me, this authorization will expire upon the date or event noted above." This change was made effective 3/1/2018. Clinical staff are meeting with their patients with admission dates prior to 3/1/2018 to seek new consents using the updated form. All patients will have the proper consents on file by 4/16/2018. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on a review of facility records and staff interviews conducted during the on-site inspection, the facility failed to perform the required initial urine screens for its potential patients. Patient #7 was admitted for treatment 11/07/2017, and was dosed with a narcotic agent on 11/07/2017, but the first documented urine screen for the patient is dated 11/27/2017. These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
An All-Staff meeting was held on 2/21/2018. During that meeting staff were re-trained on pre-screen and admission procedures including the requirement for a UDS on all prospective patients prior to admission. A hard copy of the initial UDS result is required to be given to medical staff prior to meeting with the prospective patient for admission and becomes part of their permanent record. Nursing staff will verify that the UDS results are present for review prior to each admission. Facility Director will audit each chart to ensure all required intake documentation has been 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.
|
Observations
Based on a review of patient records conducted during the on-site inspection, the facility failed to ensure that patients received the required monthly hours of psychotherapy. Patient #7 was admitted for treatment on 11/07/2017, but only received 1 hour of documented psychotherapy by the time of the on-site inspection. These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Upon admission, the admission staff will schedule the new patient's initial individual and group counseling sessions. Clinical staff are responsible for the ongoing scheduling of their caseload's individual and group counseling sessions. Facility Director will audit each new patient's chart to ensure that all required intake documentation has been completed and the patient has been scheduled for their initial individual and group counseling. By the 5th of each month, Facility Director will run the monthly schedule report. All patients who are not scheduled for their appropriate clinical services will be placed on a hold and required to schedule their clinical services prior to receiving their next medication dose. Patients who miss a scheduled individual or group session are marked as missed in their EMR. An All-Staff meeting was held on 4/4/2018 to review this process.
Psychotherapy services received by patients can be tracked in the EMR system by use of the Direct Services Analysis Report. All clinical staff are trained during their onboarding in the use of the report. As of 2/21/2018 all clinical staff are required to run the report weekly on their caseload. Facility Director will meet weekly with each clinical staff to review services due. Psychotherapy services provided and still due are reviewed and documented during clinical supervision. |
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.
|
Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to document that it notified the sending the narcotic treatment programs of the admission and initial dosing of patients that were transferred from the sending narcotic treatment program in 2 patient records reviewed. Patient #2 was transferred to the facility from another narcotic treatment program on 12/26/2017. Patient #4 was transferred to the facility from another narcotic treatment program on 08/10/2017. These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
An All-Staff meeting was held on 2/21/2018. During that meeting staff were re-trained on intake procedures including the use of the Patient Transfer Acknowledgement form in the EMR system. Additionally, we created an intake binder instruction manual that has samples of every intake/admission document used in our EMR system as well as detailed instructions on when and how each document is used. The binder was completed on 3/16/2018 and is used during onboarding and training of all clinical and admissions staff. Facility Director will ensure Transfer Acknowledgement form is completed and in chart through the intake chart audit process. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of facility records provided as part of the presubmission process, and based on staff interviews conducted during the on-site inspection, the facility failed to provide the required supervision for its counselor assistants. Staff Person #6 was hired as a support staff on 12/12/2016, and was made a high school graduate level counselor assistant on 07/10/2017. Staff Person #6 was supervised by the facility director, and not a full time clinical supervisor or a lead counselor. These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Staff person #6 was hired as a support staff on 12/12/2016 and was made a high school graduate level counselor assistant on 11/05/2017. Beginning on 2/23/2018, staff person #6 began counseling clients under the direct observation of a trained counselor. Upon successful completion of 90 days of direct observation, staff person #6 will receive the close supervision of a full time lead counselor. Direct observation is scheduled to run through 4/23/2018. Facility Director/Clinical Supervisor will ensure that all supervision is documented appropriately and co-sign all individual and group session notes. |