INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on August 14, 2024, and September 23, 2024, 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 1X dba Hazelton 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
|
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 seven personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #7 was hired on November 12, 2023 as a counselor assistant. Employee #7 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " . For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. " Employee #7 did not receive direct observation from November 12, 2023 through February 12, 2024. Employee #7 did not receive close supervision from November 12, 2023 through August 4, 2024. The facility ' s documentation shows monthly supervision with no supervision in the month of February 2024. During documented supervision only clinical skill development occurred with no documented formal case review and direct observations.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor has been trained on the correct way to complete supervision with counselor assistants. The clinical supervisor is now aware of what needs to be done and as of 10/1/2024 has started to do it with the counselor assistant we have now. The clinical supervisor is sitting in on his individual sessions, observing his groups and completing supervision weekly. The clinical supervisor is now aware of what will need to be done if another counselor assistant is hired in the future, so this does not occur again. The director will monitor the clinical supervisor's supervision to assure it is being completed correctly. |
709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
|
Observations
Based on a review of client records, the facility failed to follow their written procedures for case consults in two out of six applicable records reviewed, discharge summaries in three out of three applicable records reviewed and follow up contacts in three out of three applicable client records reviewed.
The facility' s policy and procedures manual states that case consultations occur at three, six, nine months, one year and annually thereafter.
Client #1 was admitted on February 6, 2024 and was still active at the time of the inspection. A case consultation was due no later than May 6, 2024; however, it was not completed until May 21, 2024.
Client #3 was admitted on August 29, 2023 and was still active at the time of the inspection. A case consultation was completed on February 23, 2024, and the next case consult was due no later than May 23, 2024; however, it was not completed until June 26, 2024.
The facility's policy and procedures manual stated that a discharge summary is completed within seven business days of discharge.
Client #4 was admitted on October 21, 2022 and discharged on October 17, 2023. A discharge summary was due no later than October 26, 2024; however, there is no documentation that one was completed.
Client #8 was admitted on March 5, 2024 and discharged on April 18, 2024. A discharge summary was due no later than April 29, 2024; however, it was completed on May 21, 2024.
Client #9 was admitted on July 29, 2021 and discharged on June 22, 2024. A discharge summary was due no later than July 2, 2024; however, it was not completed until July 19, 2024.
The facility ' s policy and procedures manual states that follow up contacts occur at seven days, thirty and sixty days after discharge.
Client #4 was admitted on October 21, 2022 and discharged on October 17, 2023. A follow up contact was due no later than October 24, 2024; however, there is no documentation that one was completed.
Client #8 was admitted on March 5, 2024 and discharged on April 18, 2024. A follow up contact was due no later than April 25, 2024; however, there is no documentation that one was completed.
Client #9 was admitted on July 29, 2021 and discharged on June 22, 2024. A follow up contact was due no later than June 29, 2024; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor met with the counselors on 9/26/24 and a spreadsheet was created to track when documentation is due. Each month during supervision starting on 10/1/24 the clinical supervisor will check the spreadsheet with the counselors to assure all of their documentation is up to date. The director will meet with the clinical supervisor monthly going forward to discuss where we are with clinical documentation. Having this in place will ensure documentation is not missed going forward. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
|
Observations
Based on a review of the patient records, the facility failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification in one out of four applicable records reviewed.
Patient #8 was admitted on March 5, 2024 and discharged on April 18, 2024. There is no documentation that the patient was fully informed of the risk to her or her unborn child.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Beginning on 10/1/24 the clinical supervisor will complete an audit of all new admissions the same day to assure all required forms are in the chart. If any forms are found to be missing, they will be added, and the patient will be flagged to sign the next day. The clinical supervisor will also address the staff that missed the form, it will be added to their supervision so it can be tracked if it continues. The clinical supervisor will meet with the director to go over the findings, so we can work together to ensure all required forms are completed going forward. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to administering an agent in one out of three applicable records.
Patient #8 was admitted on March 5, 2024 and discharged on April 18, 2024. There was no documentation that an informed, voluntary, written consent was signed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning on 10/1/24 the clinical supervisor will complete an audit of all new admissions the same day to assure all required forms are in the chart. If any forms are found to be missing, they will be added, and the patient will be flagged to sign the next day. The clinical supervisor will also address the staff that missed the form, it will be added to their supervision so it can be tracked if it continues. The clinical supervisor will meet with the director to go over the findings, so we can work together to ensure all required forms are completed going forward. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to provide patients with one hour per month of therapy during the third and fourth year of treatment in one out of four applicable records.
Patient #6 was admitted on July 15, 2021 and was still active at the time of the inspection. The patient received only forty-five minutes of psychotherapy in April, May and July of 2024 and only thirty minutes of psychotherapy in the month of June 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning 10/1/24 the clinical supervisor will meet with each counselor in the third week of the month to review their monthly requirements and ensure any patient who has not met their requirements is scheduled to complete them. This information will also be included in the counselor's supervision. The clinical supervisor will meet with the director to review these results so we can see where changes need to be made so we do not have the problem going forward. |