INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15 - 16, 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-II, LLC 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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715.20(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 a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient in one of two applicable records.
Patient #2 was transferred to the facility and admitted to the outpatient level of care on April 9, 2024 and was discharged June 5, 2024. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of a transferring patient.
When the facility has prior knowledge of potential patient transfers patient releases/consents will be completed in preparation when possible or on the day of the transfer.
The facility will ensure that written notification of transfer is completed and sent at the completion of all patient transfers. The written notification of transfer will be imported and recorded into the electronic medical record.
Physician Assistant will review medical portion of transfer admission documentation to verify written transfer notification was completed, sent, and documented.
Transfer processes and medical documentation will be reviewed by Physician Assistant and Facility Director in nursing staff meeting which will occur by 9/13/24.
Supervisory & Compliance staff will continue to conduct chart reviews which does include this aspect of the patient file.
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