INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 29 & 30, 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-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:
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Plan of Correction
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical by the narcotic treatment physician within the regulatory timeframe in one out of one applicable record reviewed.Patient #1 was admitted on May 17, 2022 and was still active at the time of the inspection. An annual physical was due no later than May 17, 2023; however, was not completed until May 23, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 9/1/23 a report was run of all patients, and we began checking that annual physicals have either been completed or are scheduled to be completed before the due date. Going forward each month a report will be generated to see who is due and they will be scheduled before the due date. This will be monitored by the executive director to assure it is completed. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation with all areas of regulation addressed within the regulatory timeframe in one out one applicable record reviewed.Patient #1 was admitted on May 17, 2022 and was still active at the time of the inspection. The annual evaluation was due no later than May 17, 2023; however, there was no documentation that one was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 9/1/23 the Clinical supervisor began reviewing all charts to see if any documentation was missing, including annuals. He is making a list for each counselor and the counselors will have seven days to correct anything that is missing from their charts. Going forward the Clinical Supervisor will review what is due with each counselor during their monthly supervision and will then follow up during the next supervision to assure it has been done correctly. The executive director will periodically review to ensure this procedure is being followed. |
715.24(5)(ii) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(5) Minimum requirements for long-term detoxification treatment are as follows:
(ii) A narcotic treatment program shall perform an initial drug screening test or analysis. A narcotic treatment program shall perform at least one additional random test or analysis monthly on each patient during long-term narcotic detoxification.
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Observations
Based on a review of eight patient records, the facility failed to ensure that the narcotic treatment program performed at least one additional random test or analysis monthly on each patient during long-term narcotic detoxification in one record.Patient # 6 was admitted on June 26, 2023 and was still active at the time of the inspection. There was no documentation that a urinalysis was completed in July 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Each month a patient list is printed and as drug screens are completed, they are checked off the list. For any that could not be completed a nurse's note is entered to explain why. In this case the nurse's note was not completed. Beginning 9/1/23 and going forward the executive director will review the list to assure all screens are being completed and will check to make sure nurse's notes are being completed for those who could not be completed. |
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 three out of eight records reviewed.Client #1 was admitted on May 17, 2022 and was still active at the time of the inspection. A treatment plan was completed on April 17, 2023, and the next update was due no later than June 17, 2023; however, it was not completed until June 28, 2023. The next treatment plan update was due no later than August 28, 2023; however, was one not completed at the time of the inspection. Client #4 was admitted on January 19, 2023 and was still active at the time of the inspection. A treatment plan update was completed on April 23, 2023, and the next update was due no later than June 23, 2023; however, it was not completed until July 10, 2023. Client #5 was admitted on September 1, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 20, 2023, and the next update was due no later than August 20, 2023; however, it was not completed until August 23, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 9/1/23 the Clinical supervisor began reviewing all charts to see if any documentation was missing, including treatment plans. He is making a list for each counselor and the counselors will have seven days to correct anything that is missing from their charts. Going forward the Clinical Supervisor will review what is due with each counselor during their monthly supervision and will then follow up during the next supervision to assure it has been done correctly. The executive director will periodically review to ensure this procedure is being followed. |