INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 5-6, 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 IX 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:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3 and #4 received the minimum of at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on June 28, 2021 and was still in this position at the time of the inspection. Employee # 3 was due to have the communicable disease trainings no later than June 28, 2022. Training was not completed until November 15, 2022.
Employee #4 was hired as a counselor on October 18, 2021 and was still in this position at the time of the inspection. Employee # 3 was due to have the communicable disease trainings no later than October 18, 2022. Training was not completed until November 15, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning in December of 2022, it has been made part of monthly supervision to monitor where each staff member is at with their required trainings, so we are able to assure that all mandatory trainings are completed in the time allowed. All new staff upon hire are now required to set up a DDAP account as well as a Train PA account and complete the HIV course during their first 30 days and will register for the STD/TB during the same period. This is monitored by the clinical supervisor and reviewed by the executive director monthly. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on two of eight client records reviewed, the facility failed to have verbal orders authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication within 3 business days from the time the order was given in client records # 3 and 7.
Client # 3 was admitted on August 26, 2022 and was still active at the time of the inspection. A verbal order for medication was given by the physician on December 6, 2022 but was not authenticated in writing by the physician until December 21, 2022.
Client # 7 was admitted on August 30, 2021and was discharged June 30, 2022. Verbal orders for medication were given by the physician on August 30, 2021 but was not authenticated in writing by the physician until September 10, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In December of 2022, we discovered this problem during an internal chart review. Since discovering the problem we have planned with our medical director to review orders and sign off every other day. Since December of 2022 this has been occurring and this has worked well, and the problem has not occurred since. This is being monitored going forward by the executive director. |
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 one of eight patient records reviewed, the facility failed to have a narcotic treatment physician determine the patient 's initial dose and schedule in patient record # 4.
Patient #4 was admitted on October 28, 2022 and was still active at the time of the inspection. An initial dose order was documented and authenticated by the LPN on October 28, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since being made aware of the issue during our inspection the executive director went back and reviewed charts to assure this was not done in any other chart. This was completed by 1/13/23. The nurses are now aware that they are not able to sign the orders that they enter. They were retrained on the correct way to enter a verbal order on 1/9/2023. Going forward orders will be reviewed by the executive director to check for accuracy. |
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 two of eight patient records reviewed, the narcotic treatment program failed to provide 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 # 2 and # 6.
Patient # 2 was admitted on February 10, 2022 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of March 11-April 10, April 11-May 10, June 11-July 10, and November 11-December 10, 2022.
Patient # 6 was admitted on April 7, 2022 and was discharged December 30, 2022. There was not at least 2.5 hours of psychotherapy documented the months of August 8-September 7, and November 8-December 7, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2022 annual licensing inspection.
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Plan of Correction
During our staff meeting on 1/11/23, it was reviewed with counselors the importance of holding the patients accountable for completing their required treatment time. And if a patient is unable to complete their mandatory hours it must be documented in their chart the reason why. Going forward case managers will be calling and documenting no shows daily. Counselors will document missed sessions and will add a case management note to explain if a patient is not able to complete their required hours and the reason why. The completion of these steps will be monitored by the clinical supervisor and will be reviewed by the executive director to assure this does not continue. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on one of one applicable patient record reviewed, the facility failed to include admission date, medical and psychosocial summaries in the transfer paperwork provided to the receiving facility in patient record # 5.
Patient # 5 was admitted on June 30, 2022 and discharged on December 23, 2022. Patient #5 was transferred to another facility and the documented transfer paperwork did not include the patient ' s admission date, medical and psychosocial summaries.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Any patient who is recommended to treatment at another level of care weather permanent or temporary will sign a release to release all documentation needed for a transfer to the other level of care. This was reviewed during our staff meeting on 1/18/23. Facility will utilize Methasoft transfer in/out document to note receipt and sent of transfer documents for those patients who transfer in as well as those being transferred out. The intake counselor will upload copies of transfer paperwork to Methasoft. This will be monitored by the Clinical supervisor and use of quality intake chart reviews. |
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 two applicable patient records reviewed, the facility failed to provide, in writing, documentation 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.
Patient # 2 was admitted on February 10, 2022 and was still active at the time of the inspection. There was no documentation in the patient record of the admission of the patient or initial dose given to the patient by the receiving treatment program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon the completion of an intake that is a transfer the counselor is supposed to send out a transfer acknowledgement letter. The procedure was reviewed with the current staff, at our staff meeting on 1/11/23. All were aware and stated they have been completing them. Several transfer charts were reviewed, and the verification letter was in place. Going forward, upon admission to Hazelton treatment Services, a transfer patient will have a transfer acknowledgement letter completed. This document will be sent via fax to the transferring facility to indicate the admission of patient, initial dose, and kept in the patient record. This will be monitored by the Clinical Supervisor, Executive Director, and use of quality intake chart reviews. |