INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13-14, 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-I, 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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715.19(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 patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in two of two applicable records
Patient #1 was admitted to the outpatient level of care on May 10, 2024 and was active at the time of review. Patient #1 had no psychotherapy hours during the months of June 2024 and July 2024.
Patient #6 was admitted to the outpatient level of care on March 10, 2022 and was discharged July 10, 2024. Patient #6 had only one hour of psychotherapy in the January 2024, one hour of psychotherapy in February 2024, and thirty minutes of psychotherapy in March 2024.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 16, 2021, September 27, 2022, and September 27, 2023 licensing inspections.
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Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for two of the reviewed charts.
Supervisory Staff will review requirements for counseling hours of patients in their first 2 years in clinical group supervision and staff meeting by 9/13/24. While addressing this area, it will be reviewed that all patients in their first 2 years in treatment are required to meet 2.5 hours of individual and group counseling per month.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of individual and group counseling totaling 2.5 hours/month are (1) Supervisory Staff will review counseling requirements in clinical group supervision and staff meeting. (2) Monthly individual supervision will address counseling requirements are met and barriers to meeting these requirements. (3) Clinical staff will document scheduled sessions and any cancelled /missed sessions that may occur. (4) Individual patient charts will be reviewed during specific individual supervision sessions. (5) Counseling requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient at least one hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of two applicable records.
Patient #10 was admitted to the outpatient level of care on April 26, 2021 and was active at the time of review. Patient #10 had no psychotherapy hours during the month of June 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to provide 1 hour of psychotherapy services per months for one of the reviewed charts.
Supervisory Staff will review requirements for counseling hours of patients after their first 4 years in clinical group supervision and staff meeting by 9/13/24. While addressing this area, it will be reviewed that all patients after their first 4 years in treatment are required to meet 1 hour of individual or group counseling every 2 months.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of individual and group counseling totaling 1 hour every month are (1) Supervisory Staff will review counseling requirements in clinical group supervision and staff meeting. (2) Monthly individual supervision will address counseling requirements are met and barriers to meeting these requirements. (3) Clinical staff will document scheduled sessions and any cancelled /missed sessions that may occur. (4) Individual patient charts will be reviewed during specific individual supervision sessions. (5) Counseling requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team.
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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 a review of patient records, the facility failed to document an annual evaluation of each patient ' s status, completed by the patient ' s counselor and reviewed, dated and signed by the medical director in two of four applicable records.
Patient #7 was admitted to the outpatient level of care on February 6, 1019 and was active at the time of review. An annual evaluation was due for patient #7 no later than February 6, 2024. No evaluation for 2024 was found in the patient ' s record.
Patient #10 was admitted to the outpatient level of care on April 26, 2021 and was active at the time of review. An annual evaluation was due for patient #10 no later than April 26, 2024. No evaluation for 2024 was found in the patient ' s record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 16, 2021, September 27, 2022, and September 27, 2023 licensing inspections.
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Plan of Correction
The facility failed to complete all the required documentation needed for a patient's annual evaluation in two reviewed charts.
Supervisory Staff will review requirements for annual evaluations being completed in clinical group supervision and staff meeting by 9/20/24. While addressing this area, it will be reviewed that all patients must have annual evaluations completed annually based on the date of patient admission.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of annual evaluations are (1) Supervisory Staff will review regulations around annual evaluations and education/training on timely completion of annual evaluations will be provided in clinical group supervision and staff meeting. (2) Supervisor staff will review annual evaluations compliance pre EMR reports and Tableau weekly during individual/group supervision reporting out of date/missing annual evaluations for completion which will be reviewed the following week to make sure work was completed. (3) Supervisors will review monthly to double check annual evaluations compliance, report/review any issues, and review barriers to meeting this facility policy and procedure. (4) Use of new annual documentation tracking system via Tableau which will track when annuals are due, late, or missing ? when viewed the first time after audit, if annual is missing, will be updated within the following week. (5) Review of annual documentation will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures that a comprehensive treatment plan must be completed within thirty days of admission in two of four applicable records.
Client #1 was admitted to the outpatient level of care on May 10, 2024 and was active at the time of review. A comprehensive treatment plan for client #1 was due no later than June 10, 2024. No Comprehensive treatment plan was completed for client #1.
Client #3 was admitted to the outpatient level of care on April 19, 2024 and was discharged July 22, 2024. A comprehensive treatment plan for client #3 was due no later than May 19, 2024. However, a comprehensive treatment plan was not completed for client #3 until July 28, 2024.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 27, 2023 licensing inspection.
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Plan of Correction
The facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures that a comprehensive treatment plan must be completed within thirty days of admission in two reviewed charts.
Supervisory Staff will review requirements for completion of comprehensive treatment plans by 9/20/24. While addressing this area, it will be reviewed that all patients must have comprehensive treatment plans completed within 30 days of treatment admission.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of initial comprehensive treatment plans per facilities policies and procedures are (1) Supervisory Staff will review regulations around comprehensive treatment plans and education/training on timely completion of comprehensive treatment plans will be provided in clinical group supervision and staff meeting. (2) Supervisor staff will review treatment plan compliance pre EMR reports and Tableau weekly during individual/group supervision reporting out of date/missing treatment plans for completion which will be reviewed the following week to make sure work was completed. (3) Supervisors will review monthly to double check treatment plan compliance, report/review any issues, and review barriers to meeting this facility policy and procedure. (4) Individual patient charts will be reviewed during specific individual supervision sessions and completion of comprehensive treatment plans will be part of that review. (5) Use of new treatment plan tracking system via Tableau which will track when treatment plans are due, late, or missing ? when viewed the first time after audit, if treatment plan is missing, will be updated within the following week. (6) Review of comprehensive treatment plans will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three of four applicable records.
Facility policy and procedure states that follow-up information will be obtained seven days, 30 days, and 60 days following discharge.
Client #3 was admitted to the outpatient level of care on April 19, 2024 and was discharged July 22, 2024. No follow-up information was documented in client #3 ' s record.
Client # 6 was admitted to the outpatient level of care on March 10, 2022 and discharged July 10, 2024. No follow-up information was documented in client #6 ' s record.
Client #8 was admitted to the outpatient level of care on September 13, 2017 and discharged June 17, 2024. No follow-up information was documented in client #8 ' s record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 16, 2021, September 27, 2022, and September 27, 2023 licensing inspections.
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Plan of Correction
The facility failed to provide a complete client record, which is to include follow-up information in three reviewed charts. Facility policy and procedure states that follow-up information will be obtained seven days, 30 days, and 60 days following discharge.
Supervisory Staff will review requirements for patient follow-ups in clinical group supervision and staff meeting by 9/20/24. While addressing this area, facility policies/procedure around discharge follow-ups will be reviewed.
Ongoing individual and group supervision will address progress in and completion of case consults to meet DDAP standards and regulations.
Action steps and plan to address the completion of discharge follow-ups are (1) External tracking system is implemented outside the current EMR to report and monitor completion of patient discharge follow-ups. Supervisory Staff will ensure that all clinical staff are appropriately trained on how to view and use this external tracking system. (2) Supervisory Staff will review facility policies/procedure around discharge follow-ups in clinical group supervision and staff meeting. (3) Use of Tableau dashboards to help monitor when follow-ups are due, late, or missing. (4) Discharge follow-up requirements will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting follow-up information for the outpatient records was submitted and approved by the Department for the September 16, 2021, September 27, 2022, and the September 26-27, 2023 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the August 13-14, 2024 licensing inspection.
A plan of correction for completing and documenting annual evaluations was submitted and approved by the Department for the September 16, 2021, September 27, 2022, and the September 26-27, 2023 annual licensing inspections. Completing and documenting annual evaluations was again found to be a deficiency in the August 13-14, 2024 licensing inspection.
A plan of correction for providing 2.5 hours of psychotherapy during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in the narcotic treatment program records was submitted and approved by the Department for the September 16, 2021, September 27, 2022, and the September 26-27, 2023 annual licensing inspections. Providing 2.5 hours of psychotherapy during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, was again found to be a deficiency in the August 13-14, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure the plans of correction are implemented by the corrective action date and clinical supervisor will assist in the monitoring process. Additional monitoring will occur through chart audits completed by the PTC Quality compliance team and if deficiencies are noted they will be reviewed within the month. Clinical supervisor, Quality compliance staff, and facility director will monitor continued implementation of the plans through quarterly meetings and review noticed issues occur during staff/supervision meetings. If the plan of corrections appears to be not working as written, a supervisory meeting will occur to adjust the current plans. The facility director will report to the project director the findings each quarter during PTCs regional operations meeting. |