INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 9-10, 2022, 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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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one client record that included the name of the person, agency or organization to whom disclosure is made in one record reviewed.
Client #3 was admitted on November 22, 2021 and discharged on February 8, 2022. Four informed and voluntary consents from the client for the disclosure of information signed and dated on November 22, 2021, did not include the name of the person, agency or organization to whom disclosure was to be made.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The blank forms were deleted from client #3's chart. It was reviewed with staff at our staff meeting on 3/2/22 the importance of completing releases accurately. During the intake process the releases were added but never completed, going forward all releases will be checked for accuracy by the clinical supervisor during the chart review process to assure this does not continue in the future. |
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 a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in two client records that included the specific information disclosed.
Client #2 was admitted on January 13, 2022 and was still current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a different facility signed and dated on January 13, 2022, did not include the specific information to be disclosed.
Client #12 was admitted on August 5, 2021 and was still current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a lab signed and dated on August 5, 2021, did not include the specific information to be disclosed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
New releases were completed for client #2 and client #12. It was reviewed with staff at our staff meeting on 3/2/22 the importance of completing releases accurately. During the intake process the releases are added but were not completed correctly, going forward all releases will be checked for accuracy by the clinical supervisor during the chart review process after intake to assure this does not continue in the future. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one client record that included the dated signature of witness.
Client #12 was admitted on August 5, 2021 and was still current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a funder signed and dated on August 5, 2021, did not include the dated signature of a witness on the same day the client signed. The witness signature was dated August 9, 2021.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A new release was completed for client #12. It was reviewed with staff at our staff meeting on 3/2/22 the importance of completing releases accurately. During the intake process the releases were added but not completed correctly, going forward all releases will be checked for accuracy and to assure that they are signed in a timely manner by the clinical supervisor during the chart review process after intake to assure this does not continue in the future. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one client record that included the date, event or condition upon which the consent will expire.
Client #4 was admitted on August 2, 2021 and was discharged on December 14, 2021. An informed and voluntary consent from the client for the disclosure of information that listed dual enrollment for the name of the person, agency or organization to whom disclosure is made, that was signed and dated on August 2, 2021, did not include the date, event or condition upon which the consent will expire.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
It was reviewed with staff at our staff meeting on 3/2/22 the importance of completing all documents accurately. During the intake process the dual enrollment was added but never completed correctly, going forward all documents including the dual enrollment will be checked for accuracy by the clinical supervisor during the chart review process after intake to assure this does not continue in the future. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in three client records that included a copy of the client consent was offered to the client and a copy maintained in the client record.
Client #1 was admitted on July 12, 2021 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a probation department that was signed and dated October 2, 2021, did not indicate a copy of the consent was offered to the client.
Client #2 was admitted on January 13, 2022 and was still current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information for a government agency and a funder that were signed and dated on January 13, 2022, did not indicate a copy of the consent was offered to the client.
Client #10 was admitted on January 10, 2022 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information for a lab that was signed and dated on January 10, 2022, did not indicate a copy of the consent was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
New releases were completed for client #1, client #2 and client #10. It was reviewed with staff at our staff meeting on 3/2/22 the importance of completing releases accurately. This included completing all check boxes. During the intake process the releases are added but were not completed correctly, going forward all releases will be checked for accuracy by the clinical supervisor during the chart review process after intake to assure all check boxes and other information is complete so this does not continue in the future. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of two applicable client records, the project staff failed to notify two clients, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 2/1/22 this facility created a form letter with an area to write specific reason for discharge. This letter will be mailed to each client who is discharged with no other contact by the counselor. Since 2/1/22 every client who is discharged who could not be reached in person or by phone will have a letter mailed to them stating reason for discharge and a copy will be kept in their chart. On a monthly basis the clinical supervisor will check the discharged charts during the audit process to assure the letters are being sent. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of two applicable client records, the project staff failed to notify two clients, they had an opportunity to request reconsideration of the decision terminating treatment.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 2/1/22 this facility created a form letter with an area to write specific reason for discharge, and explaining the process for reconsideration that will be mailed to each client who is facing discharge and has had no other contact. Since 2/1/22 every client who is being considered for discharge who could not be reached in person or by phone will have a letter mailed to them by their counselor stating reason for possible discharge and the process for reconsideration and a copy will be kept in their chart. On a monthly basis the clinical supervisor will check the discharged charts during the audit process to assure the letters are being sent. |
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 a review of seven patient records, the narcotic treatment program failed to provide three patients 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.
Patient #1 was admitted on July 12, 2021 and was current at the time of the inspection. Patient #1 only received one hour and twenty minutes of psychotherapy during the month of January.
Patient #3 was admitted on November 22, 2021 and discharged on February 8, 2022. Patient #3 did not receive any psychotherapy during the month of January.
Patient #5 was admitted on December 27, 2021 and was current at the time of the inspection. Patient #5 only received one and a half hours of psychotherapy during the month of January.
These findings were reviewed with the program staff during the licensing process.
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Plan of Correction
During the month of January three of our four counselors were out with covid. The staff shortage due to covid caused there to be missed sessions through no fault of the client. This was not documented in the client's chart, but should have been. In our staff meeting on 3/2/22 the importance of documenting anything of importance was reviewed with the staff. Going forward any client who does not meet their required treatment time will have a case management note added to their chart indicating the reason why their required treatment time was not completed. the clinical supervisor will monitor that this has been completed on a monthly basis. |