INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 3-4, 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-III, 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 and the date of the initial dose given to the patient in one of two applicable records.
Patient #7 was transferred to the facility and admitted to the outpatient level of care on June 26, 2024 and was active at the time of review. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient, or the date of the initial dose given to the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Action Steps
1: Clinical supervisors and Executive Director met with counselors on 9/5/24 for group supervision and reviewed the expectations regarding completing transfer documentation.
2: Clinical supervisors and counselor will monitor the documentation that is faxed along with the fax confirmation sheet the same day as the admission
3: Clinical supervisor will maintain a spreadsheet of transfers to ensure that all documentation in writing is given to the transferring narcotic treatment program and monitor this spreadsheet daily. |