INITIAL COMMENTS
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This report is a result of an on-site provisional license and methadone monitoring follow-up inspection conducted on April 8, 2025 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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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 five of seven applicable records.
Client #1 was admitted to the outpatient level of care on January 8, 2025 and was active at the time of review. A comprehensive treatment plan for client #1 was due no later than February 8, 2025. A comprehensive treatment plan was completed February 21, 2025.
Client #2 was admitted to the outpatient level of care on January 30, 2025 and was active at the time of review. A comprehensive treatment plan for client #2 was due no later than March 2, 2025. A comprehensive treatment plan was completed March 26, 2025.
Client #4 was admitted to the outpatient level of care on December 3, 2024 and was active at the time of review. A comprehensive treatment plan for client #4 was due no later than January 3, 2025. A comprehensive treatment plan was completed March 14, 2025.
Client #5 was admitted to the outpatient level of care on November 7, 2024 and was active at the time of review. A comprehensive treatment plan for client #5 was due no later than December 7, 2024. A comprehensive treatment plan was completed December 23, 2024.
Client #6 was admitted to the outpatient level of care on February 13, 2025 and was active at the time of review. A comprehensive treatment plan for client #6 was due no later than March 13, 2025. A comprehensive treatment plan was completed March 28, 2025.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 27, 2023 and the August 14, 2024 licensing inspections.
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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.
Supervisory Staff will review requirements for completion of comprehensive treatment plans in staff meeting and group clinical supervision by 5/16/24. While addressing this area, it will be reviewed that all patients must have comprehensive treatment plans completed within 30 days of treatment admission and all new admissions will be placed on a stop dose on treatment day 14 to make sure this occurs.
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) all new admissions will be placed on a stop dose on treatment day 14 to make sure first comprehensive treatment plan is completed prior to day 30. (2) 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 by 5/16/25. (3) Supervisor staff will weekly review treatment plan compliance pre EMR reports and Tableau sending out due and upcoming due treatment plans reports to all clinical staff on a weekly basis to guaranty completion compliance. (4) Supervisors will review monthly to double check treatment plan compliance, report/review any issues, and review barriers to meeting this facility policy and procedure. (5) 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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709.17(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 comprehensive treatment plans was submitted and approved by the Department for the September 27, 2023 and the August 14, 2024 annual licensing inspections. Completing and documenting comprehensive treatment plans was again found to be a deficiency in the April 8, 2025 licensing inspection.
This finding was reviewed with the 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. Facility director will review Tableau compliance dashboard to ensure all initial comprehensive treatment plans are completed. 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 weekly meeting through the month of May and then continued quarterly meetings. If the plan of corrections appears to be not working as written, a supervisory meeting will occur to adjust the current plans. |