INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, methadone monitoring inspection and complaint investigation conducted on July 12 - 13, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, the allegations against Pinnacle Treatment Centers PA-VIII, LLC were determined to be partially substantiated. Based on the findings of the on-site inspection and complaint investigation, Pinnacle Treatment Centers PA-VIII, 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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715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of patient records, the facility failed to document the individual had reached eighteen years of age prior to the administration of a narcotic agent in one of four records reviewed on July 12 - 13, 2021.
Patient # 6 was admitted January 13, 2021 and discharged February 16, 2021. Patient # 6 was administered methadone on January 13, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Administrative Assistant will maintain onsite a photograph of each patient which includes the patient's name and birth date, ensuring that they have reached the age of 18 years. Staff will complete onsite training, which will include the verification of a patient's age and how to upload into electronic filing system. The narcotic treatment program shall update the photograph every 3 years. This will be effective immediately. Director and or Clinical Supervisor will audit all intake charts, to verify accurate information was obtained. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to document the verification of the individual's identity including name, address, and date of birth prior to the administration of a narcotic agent in one of four records reviewed on July 12 - 13, 2021.
Patient # 6 was admitted January 13, 2021 and discharged February 16, 2021. Patient # 6 was administered methadone on January 13, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Administrative Assistant will maintain onsite a photograph of each patient which includes the patient's name and birth date and correct address in which they currently reside and ensuring that they have reached the age of 18 years. Staff will complete onsite training, which will include the verification of a patient's age and how to upload into electronic filing system. The narcotic treatment program shall update the photograph every 3 years. This will be effective immediately. Director and or Clinical Supervisor will audit all intake charts, to verify accurate information was obtained. |
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 document each patient received an average of 2.5 hours of psychotherapy per month in three of five patient records reviewed on July 12 - 13, 2021.
Patient # 1 was admitted January 20, 2020. The following psychotherapy hours were documented in patient record # 1: February 2021 - 2 hours, March 2021 - 1 hour, April 2021 - 1.25 hours, May 2021 - .5 hour and June 2021 - .5 hour.
Patient # 3 was admitted May 18, 2020 and discharged May 10, 2021. The following psychotherapy hours were documented in patient record # 3: February 2021 - 1.5 hours, March 2021 - 0 hours and April 2021 - 0 hours.
Patient # 5 was admitted January 18, 2021 and discharged May 19, 2021. The following psychotherapy hours were documented in patient record # 5: February 2021 - 0 hours, March 2021 - .75 hours and April 2021 - 0 hours.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor from Charleroi Treatment services will ensure documentation of time required for psychotherapy has been completed monthly by the counselors, completing a minimum of 2.5 hours monthly. Clinical Supervisor will utilize tracking form to document time need and time received for each patient at the facility. Clinical Supervisor will retrain staff on regulations pertaining to counseling hours required. This will begin on 7/28/2021 and remain ongoing. |
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 document each patient received an average of 1 hour of psychotherapy per month in two of two patient records reviewed on July 12 - 13, 2021.
Patient # 4 was admitted January 11, 2019 and discharged June 11, 2021. The following psychotherapy hours were documented in patient record # 4: March 2021 - 0 hours, April 2021 - 0 hours and May 2021 - 0 hours.
Patient # 7 was admitted December 26, 2017. The following psychotherapy hours were documented in patient record # 7: February 2021 - .75 hour, March 2021 - .5 hour, April 2021 - .5 hour, May 2021 - .5 hour and June 2021 - .5 hour.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor from Charleroi Treatment services will ensure documentation of time required for psychotherapy has been completed monthly by the counselors, completing a minimum of 1 hour monthly. Clinical Supervisor will utilize tracking form to document time need and time received for each patient at the facility. Clinical Supervisor will retrain staff on regulations pertaining to counseling hours required. This will begin on 7/28/2021 and remain ongoing. |
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 patient records, the facility failed to document follow-up information at seven days and thirty days after discharge, per facility policy, in three of four patient records reviewed on July 12 - 13, 2021.
No follow-up information was documented in the following records:
Patient # 3 was admitted May 18, 2020 and discharged May 10, 2021.
Patient # 4 was admitted January 11, 2019 and discharged June 11, 2021.
Patient # 5 was admitted January 18, 2021 and discharged May 19, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor upon patient discharge from facility, will schedule follow up VIA electronic monitoring system, to assigned counselor, to be completed, one at 7 days and one at 30 days. Clinical Supervisor will conduct chart audits for all patients discharged, to ensure documentation is completed. Executive Director and Clinical Supervisor will also conduct onsite training on how to schedule discharge follow ups. This will occur and be implemented as of 7/28/2021. |