INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on March 17-18, 2021 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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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.
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Observations
Based on one of twelve client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to keep the specific information disclosed within the limits of 255.5.Client # 10 was admitted on September 14, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a probation officer dated November 30, 2020 allowed for the release of General medical record-history and physical, physician and nurse and other provider notes, social work/case management notes, psychiatric mental health/developmental disabilities information, consultation report, x-ray, test, and study results.These findings were reviewed with facility staff during the licensing processThis is a repeat citation from the February 27, 2020 inspection.
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Plan of Correction
On 4/21/21, an all staff training was held by ED Jen Tichy and Lead Counselor to review appropriate completion of releases of information for specific parties. Also, on 3/31/21, ROI templates were added for probation, parole, and other entities to ensure that ROI's for specific entities were completed appropriately and under the guidelines of 42 CFR Part 2 as well as Federal Confidentiality guidelines. |
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
Based on two of seven patient records reviewed, the facility failed to provide documentation of identification verifying the patient has reached 18 years of age in patient records # 1 and 5. Patient # 1 was admitted on December 14, 2020 and was still active at the time of the inspection. There was no documentation of identification verifying the patient has reached 18 years of age in the patient record. Patient # 5 was admitted on March 18, 2020 and was discharged on October 7, 2020. There was no documentation of identification verifying the patient has reached 18 years of age in the patient record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/31/21, patient #1's chart was updated with a valid state identification verifying the patient has reached the age of 18 years old. Patient 5 was a discharged patient, therefore her chart was unable to be updated.
An all staff training was conducted by ED Jen Tichy and Lead Counselor on 4/21/21 reviewing the admission and intake process, as well as current patients, to ensure that all patient files have documentation of identification verifying the patient has reached 18 years of age. Monthly chart audits will continue to be conducted to ensure that all patient records have identification. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on two of seven patient records reviewed, the facility failed to provide documentation of identification verifying the individual 's identity, including name, address, date of birth in patient records # 1 and 5. Patient # 1 was admitted on December 14, 2020 and was still active at the time of the inspection. There was no documentation of identification verifying the individual 's identity, including name, address, date of birth in the patient record. Patient # 5 was admitted on March 18, 2020 and was discharged on October 7, 2020. There was no documentation of identification verifying the individual 's identity, including name, address, date of birth in the patient record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/31/21, patient #1's chart was updated with a valid state identification verifying the patient has reached the age of 18 years old. Patient 5 was a discharged patient, therefore her chart was unable to be updated.
An all staff training was conducted by ED Jen Tichy and Lead Counselor on 4/21/21 reviewing the admission and intake process, as well as current patients, to ensure that all patient files have documentation of identification verifying the patient has reached 18 years of age. Monthly chart audits will continue to be conducted to ensure that all patient records have identification. A scheduled event was also placed in all patients chart to ensure that all patient's identification is updated every 3 years, per DDAP regulation. |
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 one of two applicable patient records reviewed, the facility failed to provide documentation of the narcotic treatment physician reviewing the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.Patient # 7 was admitted on November 7, 2017 and was discharged on January 18, 2021. There was no documentation of a dose review occurring at least twice a year for the year 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff training was conducted on 4/21/21 by ED Jen Tichy and Lead Counselor to review the 6 month dose review process for all patients. All patient charts were reviewed to ensure that HTS's EHR generates scheduled events to trigger for 6 month dose reviews, as well as all documentation in the charts reflect completion of the 6 month dose reviews, as well as any and all attempts to schedule such appointment. Counselors will review patient charts monthly to ensure that all patients due for a dose review are alerted to schedule and complete the review. Monthly chart audits will continue to be completed to ensure compliance with this regulation and reviewed by the Lead Counselor. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide documentation of the narcotic treatment physician making the determination and documenting the rationale for providing take-home medication under the approved blanket exception for allowing take homes. Also, the facility policy and procedure manual for the exception to take homes indicates a determination must be made by the doctor prior to allowing take home medication.Patient # 3 was admitted on March 18, 2018 and was still active at the time of the inspection. There was no documentation of the narcotic treatment physician making the determination prior to allowing the patient 13 take-home bottles. There was only a case note stating the patient was receiving 13 take-home bottles.Patient # 4 was admitted on August 5, 2020 and was still active at the time of the inspection. There was no documentation of the narcotic treatment physician making the determination for prior to allowing the patient 14 take-home bottles. Patient # 7 was admitted on November 17, 2017 and was discharged on January 18, 2021. There was no documentation of the narcotic treatment physician making the determination for prior to allowing the patient 13 take-home bottles. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Per discussion with NTP and ED Jen Tichy on 4/30/21, the narcotic treatment physician will provide documentation of rationale for providing take0home medication under the approved blanket exception for allowing takehomes. The NTP and facility will use the in house exception form which is located in the programs EHR, which allows the NTP to document the rationale for providing take-home medication. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on five of seven patient records reviewed, the facility failed to have a narcotic treatment physician determine the patient 's initial and subsequent dose and schedule with each dosage change written and signed by the narcotic treatment physician. Patient # 1 was admitted on December 14, 2020 and was still active at the time of the inspection. The initial dose was determined by the CRNP on December 14, 2020. A subsequent dose was determined by the CRNP on January 25, 2021.Patient # 2 was admitted on June 18, 2020 and was still active at the time of the inspection. The initial dose was determined by the CRNP on June 18, 2020. A subsequent dose was determined by the CRNP on September 22, December 21, 2020, January 21, and 28, 2021. Other subsequent doses were determined by the physician assistant on July 6, 13, and 20, 2020. A "small increase" was documented in the record without the amount of the increase. Patient # 4 was admitted on August 5, 2020 and was still active at the time of the inspection. The initial dose was not documented in the patient record. A case note dated August 5, 2020 stated "see forms completed today" however, those forms were not available. A nurse note on August 5, 2020 states "started 116 mg + 3 take-home bottles".Patient # 5 was admitted on March 18, 2020 and was discharged on October 7, 2020. A case note dated March 26, 2020 indicated a dose determination by the CRNP. Other subsequent doses were determined by the physician assistant on July 10 and 13, 2020.Patient # 6 was admitted on November 17, 2020 and was discharged on December 22, 2020. The initial dose was determined by the CRNP on November 17, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Per discussion with the Narcotic Treatment physician and ED Jen Tichy on 4/30/21, the NTP will determine the patient's initial and subsequent dose. The dosage change will be written and signed by the NTP and any dosage change by the CRNP will be provided via verbal order from the Narcotic Treatment Physician and signed by the Narcotic Treatment Physician. |
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 # 1,2,3,4.Patient # 1 was admitted on December 14, 2020 and was still active at the time of the inspection. A review of progress notes indicated 2 hours of psychotherapy December 14, 2020-January 14, 2021 and 1 hour and 15 minutes the month of February 14-March 14, 2021.Patient # 2 was admitted on June 18, 2020 and was still active at the time of the inspection. A review of progress notes indicated 1 hour and 45 minutes of psychotherapy the month of February, 1 hour in January, 30 minutes in December, and 1 hour and 25 minutes in November.Patient # 3 was admitted on March 18, 2018 and was still active at the time of the inspection. A review of progress notes indicated 1 hour of psychotherapy the month of February, and 1 hour in January.Patient # 4 was admitted on August 5, 2020 and was still active at the time of the inspection. A review of progress notes indicated 1 hour of psychotherapy the month of February, 1 hour in January, and 1 hour in December.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff training was conducted on 4/21/21 by ED Jen Tichy to review the DDAP regulations regarding standard patient counseling requirements (2.5 hours). Weekly direct service reports will be reviewed by ED Jen Tichy to ensure compliance with this regulation. Lead Counselor will also review direct service reports in weekly supervision with counselors to ensure that patients required to have 2.5 hours, 1 hour, or 1/2 hour of psychotherapy are receiving the appropriate clinical time. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on one of one applicable patient records reviewed, the facility failed to document transfer materials sent to the receiving narcotic treatment program. Patient # 5 was admitted on March 18, 2020 and was transferred on October 7, 2020. A case note on October 7, 2020 indicated the patient was transferred to another facility however, there was no documentation of the required paperwork in the patient record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff training was conducted on 4/21/21 by ED Jen Tichy to review the transfer process to ensure that all documentation received by HTS from a transferring facility as well as all transfer documentation HTS sends to a transferring facility, along with the fax confirmation are scanned into the patient record upon completion of fax transmittal. Monthly chart audits will continue to be conducted and will in addition include review of patient charts for transfer record documentation. |
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
Based on one of one applicable patient records reviewed, the facility failed to document the notification of the patient's admission and initial dose given to the referring facility. Patient # 4 was admitted on August 5, 2020 and was still active at the time of the inspection. A letter in the patient record indicated notifying the referring facility of admission however, the initial dose was not documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/31/21, Pinnacle Treatment Centers Director of Operations reviewed the transfer acknowledgement form and updated the form to generate the initial dose in the EHR for all patients. Continued audits of those forms will be completed to ensure that the initial dose is documented on the transfer acknowledgement form and appropriately sent to the referring facility. |