INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 21, 2023 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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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of seven patient records, the facility failed to ensure that the narcotic treatment physician reviewed the dosage levels at least twice a year in one patient record.
Patient #4 was admitted on July 18, 2019, and was still active at the time of the inspection. The patient record contained documentation of a dose review on September 22, 2021; however, the record contained no subsequent dose reviews.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In treatment team with the NTP, as well as counselors, on 3/1/2023, training surrounding scheduled events in Methasoft occurred, such as reviewing intake dates and ensuring that all scheduled events (required documentation) for each patient on the counselors caseload accurately reflected the required documentation each month/bi- annually/and annually. Clinical Supervisor will review each caseload weekly with the NTP and ensure all required bi-annual reviews and documentation has been completed as required. Executive Director and Clinical Supervisor will continue to conduct monthly chart audits to also review required documentation and ensure that it is reflected and that the NTP remains in compliance with bi-annual dose reviews. |
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 a review of seven patient records, the facility failed to document an annual clinical evaluation of the patient in one of three applicable client records.
Patient #5 was admitted on June 16, 2021 and was still active at the time of the inspection. The most recent annual evaluation was due no later than June 16, 2022; however, it was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In treatment team with the counselors on 3/1/2023, training surrounding scheduled events in Methasoft occurred, such as reviewing intake dates and ensuring that all scheduled events (required documentation) for each patient on the counselors caseload accurately reflected the required documentation each month/bi- annually/and annually. Clinical Supervisor will review each counselors caseload in monthly supervision and ensure all required monthly/bi-annual/and annual documentation has been completed as required, as well as review scheduled events for the required documentation in Methasoft are accurate and not missing, to ensure that no required documentation is missed moving forward. Executive Director and Clinical Supervisor will continue to conduct monthly chart audits to also review required documentation and ensure that it is reflected and completed in the patient chart. |