INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 16 & 17, 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 dba 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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715.6(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
Based on a review of the physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of April 30-May 6, 2023, the patient census was 220. The facility was required to provide at least 22.0 physician hours. There were only 15 physician hours documented. During the week of May 7-13, 2023, the patient census was 221. The physician was required to provide 22.1 physician hours. There were only 19.5 physician hours documented.During the week of May 14-20, 2023, the patient census was 223. The physician was required to provide 22.3 physician hours. There were only 21 physician hours documented. During the week of May 21-27, 2023, the patient census was 224. The physician was required to provide 22.4 physician hours. There were only 20 hours documented. During the week of May 28-June 3, 2023, the patient census was 218. The physician was required to provide 21.8 physician hours. There were only 16 hours documented. During the week of June 4-10, 2023, the patient census was 219. The physician was required to provide 21.9 physician hours. There were only 20 hours documented. During the week of June 18-24, 2023, the patient census was 224. The physician was required to provide 22.4 physician hours. There were only 15 hours documented. During the week of July 2-8, 2023, the patient census was 228. The physician was required to provide 22.8 physician hours. There were only 10 hours documented. During the week of July 9-15, the patient census was 226. The physician was required to provide 22.6 physician hours. There were only 21 hours documented. During the week of July 23-29, 2023, the patient census was 231. The physician was required to provide 23.1 physician hours. There were only 21 hours documented. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 10/25/23, the medical director will work 3 8 hour days at the program, which will equal 24 hours per week, which will meet the regulation of 1 hour of physician time a week, onsite for every ten patients.
As of 11/6/23, the facility will employ a Certified Registered Nurse Practitioner, who will begin providing 2/3 of the required physician hours. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of eight records reviewed.Client #1 was admitted on October 21, 2019 and was still active at the time of the inspection. A treatment plan update was completed on May 12, 2023, and the next update was due no later than July 12, 2023; however, it was not completed until July 24, 2023. The next treatment plan update was due no later than September 24, 2023; however, it was not completed until September 29, 2023. Client #3 was admitted on February 1, 2023 and was discharged on October 11, 2023. A treatment plan update was completed on May 1, 2023, and the next update was due no later than July 1, 2023; however, it was not completed until July 3, 2023.Client #6 was admitted on February 1, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 2, 2023, and the next update was due no later than May 2, 2023; however, it was not completed until May 5, 2023.Client #7 was admitted on September 27, 2017 and was still active at the time of the inspection. A treatment plan update was completed on February 27, 2023, and the next update was due no later than April 27, 2023; however, it was not completed until May 8, 2023. The next treatment plan update was due no later than July 8, 2023; however, it was not completed until July 10, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/18/2023, Executive Director met with all counselors during treatment team meeting to review the treatment plan update changes.
Treatment plan update timelines were reviewed and counselors were informed that when the treatment plan update is created, the next treatment plan update is due 60 calendar days from the date of creation. This change will be made as of 10/19/23.
Executive Director will monitor treatment plan timeliness in weekly supervisions with the counselors, to ensure that treatment plans are completed on or before the due date. Executive Director will also completed monthly chart audits of a sampling of charts, to ensure that treatment plans are completed on or before the due date. |