INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on February 25-27, 2020 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 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
|
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
|
Observations
Based on a review of facility records and the facility ' s website, Hanover Treatment Center was found not be in compliance with notifying the Department of a change in activity to include providing Buprenorphine as a service. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director will coordinate with Regional Director and IT to restructure the information on the website, as well as the documents in the electronic health records for the York Suboxone Program to more accurately reflect operations of both Hanover Treatment Services and the York Suboxone Program. Facility will be in compliance by April 30, 2020. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on three of eight client records reviewed on February 25-27, 2020, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records # 3, 4, and 5. Client # 3 was admitted on May 29, 2019 and was still active at the time of the inspection. An informed and voluntary consent to disclose form dated May 29, 2019 to Family First did not provide the information to be disclosed. The disclosure form allowed for "coordination of care. " Client # 4 was admitted on February 14, 2019 and was still active at the time of the inspection. An informed and voluntary consent to disclose form dated February 14, 2019 to multiple funding agencies allowed for the disclosure of the admission summary and current dose and dose history.Client # 5 was admitted on January 23, 2019 and was discharged on April 15, 2019. Informed and voluntary consent to disclose forms dated January 23, 2019 to funding sources and the Department of Public Welfare, allowed information exceeding 255.5 (b). The consent forms allowed for the release of an admission summary, treatment plans, lab tests, physical exam, progress notes, drug and alcohol assessment, drug and alcohol treatment notes, current dose and dose history, psychosocial evaluation, and discharge summary.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On March 11, 2020, Executive Director and Lead Counselor conducted a training on consent forms and how to ensure they are appropriately filled out. Executive Director and Lead Counselor reviewed Confidentiality regulations related to consent forms for certain parties, such as employers, probation/parole, and funding sources. Executive Director and Lead Counselor advised all staff to utilize the pre-populated release forms for specific entities, which have been created and reviewed by our Legal and Compliance department to ensure that they met all confidentiality regulations and guidelines. All patient release forms who were not in compliance will be completed again, signed by both client and staff and reviewed by Lead Counselor to ensure that they are correct and fall under confidentiality regulations. All previous releases that are not in compliance will be expired. Facility will be in compliance as of 3/30/2020 at the completion of the training between Executive Director, Lead Counselor, and all staff, as well as at the completion of all new release forms. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the project ' s policy and procedure manual on February 25-27, 2020, the project failed to develop and implement procedures in responding to an event at the facility requiring the presence of police, fire or ambulance personnel.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Executive Director will work with Regional Director and Quality Improvement to ensure that the reporting of all unusual incidents policy and procedure are addressed in one policy and procedure that address 709.34 (a) (1-8) and (b) (1-5), with a separate procedure for each unusual incident. Hanover Treatment Services will continue to use our current emergency management 411 manual which addresses all of those areas, including but not limited to monthly fire drills, annual drills on medical emergencies, and violence on premises. Facility will be in compliance by April 30, 2020. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
|
Observations
Based on one of eight patient records reviewed on February 25-27, 2020, the program failed to provide documentation of treatment plan updates in patient record # 6. Patient # 6 was admitted on February 26, 2019 and was discharged on November 17, 2019. A treatment plan was developed on June 24, 2019 with the next update due on August 24, 2019. The treatment plan update did not occur until October 2, 2019. These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
On March 11, 2020, Executive Director and Lead Counselor conducted a meeting to re-train clinicians on the DDAP charting timelines for treatment plan reviews. DDAP charting timeline documentation was provide to the clinicians to ensure their awareness of the charting timelines. To ensure timeliness of treatment plan reviews, weekly chart audits will be completed by the clinicians, which will then be reviewed by the Lead Counselor. Executive Director will then audit the findings to ensure that we are meeting the charting timelines for treatment plan reviews. QI will conduct a quarterly site visit and chart audits to ensure that all required documentation is being completed on time. Facility will be in compliance upon completion of the all staff meeting on 03/11/2020. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on three of eight client records reviewed on February 25-27, 2020, the facility failed to provide a consent to treatment form in client records # 11, 14, and 15.Client # 11 was admitted on September 26, 2019 and was still active at the time of the inspection. There was not a valid consent to treatment in the client record. Client # 14 was admitted on April 9, 2019 and was discharged on February 24, 2020. There was not a valid consent to treatment in the client record. Client # 15 was admitted on February 19, 2019 and was discharged on February 5, 2020. There was not a valid consent to treatment in the client record. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On March 11, 2020, Executive Director and Lead Counselor conducted a training regarding consents and valid consent forms. To ensure compliance moving forward, counselors were instructed at the end of the month to pull the Expiring Release report from our electronic health record, which provides a list of all upcoming expiring releases, to ensure that all clients have valid releases in their chart, that have not expired. Facility will be in compliance upon completion of the all staff meeting on 3/11/2020. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on five of eight client records reviewed on February 25-27, 2020, the project failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan. Client # 11 was admitted on September 26, 2019 and was still an active client at the time of the inspection. The treatment and rehabilitation plan dated November 14, 2019 through January 18, 2020 indicated individual sessions to occur one hour weekly. The client record of service and progress notes documented sessions to only have occurred on November 14 and December 5, 2019.Client # 12 was admitted on March 6, 2018 and was still an active client at the time of the inspection. The treatment and rehabilitation plan dated November 5, 2019 through January 3, 2020 indicated individual sessions to occur one hour monthly. The client record of service and progress notes documented sessions to only have occurred on November 26, 2019.Client # 14 was admitted on April 9, 2019 and was discharged on February 24, 2020. The treatment and rehabilitation plan dated October 21, 2019 and December 5, 2019 indicated individual sessions to occur one hour monthly. The client record of service and progress notes documented no sessions to have occurred in November 2019 or January 2020.Client # 15 was admitted on February 19, 2019 and was discharged on February 5, 2020. The last two documented treatment and rehabilitation plans were dated August 19, 2019 and October 21, 2019. Each indicated individual sessions to occur one hour monthly. The record of service and progress notes document no sessions to have occurred in January 2020.Client # 16 was admitted on September 20, 2018 and was discharged on August 22, 2019. The treatment and rehabilitation plan dated May 16, 2019 and July 23, 2019 indicated individual sessions to occur one hour monthly. The client record of service and progress notes document a one half-hour session to have occurred on June 13, 2019 and no sessions to have occurred in July 2020.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On March 11, 2020 Executive Director and Lead Counselor conducted a meeting regarding counseling services and ensuring that treatment and rehabilitation plans reflect the accurate time in treatment, as well as ensuring that clients receive the appropriate time in treatment or missed session notes are documented as to why adequate counseling services were not provided. Counselors were re-trained to ensure that missed counseling notes were placed in the chart to document if a client did not attend session and why. Counselors were also instructed to utilized brief contact notes in the electronic health record to reflect attempts to contact the client if they were to miss their counseling services, as well as case consultation forms documenting conversations between the counselor and staff reflecting treatment plan updates to reflect appropriate counseling services. Facility will be in compliance upon completion of the staff meeting on 3/11/2020. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on three of eight client records reviewed on February 25-27, 2020, the facility failed to provide documentation of an aftercare plan in client records # 8, 14, and 15.Client # 8 was admitted on January 27, 2020 and successfully discharged on February 3, 2020. There was no documentation of an aftercare plan in the client record.Client # 14 was admitted on April 9, 2019 and successfully discharged on February 24, 2020. There was no documentation of an aftercare plan in the client record.Client # 15 was admitted on February 19, 2019 and successfully discharged on February 5, 2020. There was no documentation of an aftercare plan in the client record.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On March 11,2020 Executive Director and Lead Counselor conducted a training in regards to the use of aftercare plans for clients who are actively tapering from their medication. Counselors were instructed that the aftercare form, located in the forms/admission tab in the electronic health record is to be updated (at minimum) a month prior to the client's anticipated discharge date. If a client is AMA from treatment, that will be reflected in a brief contact note and that the aftercare plan was not able to be completed due to the client leaving treatment AMA. Facility will be in compliance upon completion of the staff training on 03/11/2020. |