INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 24, 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 -VIL, LLC d/b/a 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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709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for discharge summaries for clients in two out of three applicable client records reviewed.
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 April 30, 2019 and discharged on February 19, 2024. A discharge summary was due no later than February 27, 2024; however, it was not completed until March 6, 2024.
Client #5 was admitted on May 15, 2019 and discharged on August 29, 2024. A discharge summary was due no later than September 6, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director held an all staff meeting on 10.2.24 to review DDAP citations. Training will be provided to the counselors regarding discharge summary completion and due dates for discharge summaries, which are due 7 days post discharge. Clinical Supervisor will review each caseload weekly with the counselors in supervision and ensure all required discharge summaries has been completed. Executive Director and Clinical Supervisor will continue to conduct monthly chart audits to also review required documentation for discharge and ensure that it is reflected and that the counselors remain in compliance with discharge summary due dates and completion. |
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 of the patient's status by the patient's counselor and reviewed, dated and signed by the medical director by the regulatory time frame in two out of five applicable records.
Patient #5 was admitted on May 15, 2019 and discharged on August 29, 2024. An annual evaluation was due no later than May 15, 2024; however, it was not completed until May 16, 2024.
Patient #6 was admitted on January 11, 2022 and was still active at the time of the inspection. An annual evaluation was due no later January 11, 2024; however, it was not completed until February 19, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director held an all staff meeting on 10.2.24 to review DDAP citations. All staff training was provided on managing caseloads and caseload documentation to ensure that annual clinical evaluations are scheduled and completed on or prior to the due date (anniversary of the patient's intake date). Executive Director and Clinical Supervisor will conduct monthly chart audits and review patient charts for annual clinical evaluation documentation and completion on or prior to the due date. The monthly audits will assist in assuring that the corrective action and training is being implemented and annual clinical evaluations and documentation of such are being completed on or prior to the due date and that the corrective action is being implemented. Clinical Supervisor will continue to monitor and share upcoming due dates for annual clinical evaluations via weekly spreadsheets sent to the counselors. |