INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 23-24, 2023 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, Inc., PA-V, 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit heaters that are not permanently mounted or installed.
A portable heater was observed in a counseling office during the physical plant inspection conducted on January 23, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. On 2/6/23- All staff was provided education on the 705.26 regulation and was required to remove all heating/cooling devices in each office
2. Executive Director will provide random checks of all offices during the internal physical plant inspection on a semi-annual basis to ensure compliance of 705.26 regulation. This will be ongoing.
3. All internal physical plant inspections will be conducted and documented in IAuditor according to the environmental care calendar. This will be ongoing. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client ' s treatment at the project in one of one client records.
Client #6 was admitted on December 29, 2021 and involuntarily terminated on May 17, 2022. There was no documentation that the client was provided with a written notification of termination in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. On 2/6/23 staff meeting- Regulation 709.33 (a) Notification of termination was reviewed with staff.
2. Executive Director and Clinical Supervisor will review every notification of termination prior to providing to a patient. This will be ongoing.
3. Executive Director will review the chart to ensure compliance is met with 709.33 with each identified patient. |
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 that it notified the transferring facility, in writing, of patient's admission and date of initial dose in two of three patient records.
Patient #1 transferred and was admitted on April 27, 2022 and is currently active. There was no documentation a written transfer acknowledgement was sent to the transferring facility in patient record #1.
Patient #3 transferred and was admitted on October 3, 2022 and is currently active. There was no documentation a written transfer acknowledgement was sent to the transferring facility in patient record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. On 2/6/23- 715.20(4) Patient transfers was reviewed with entire clinic and regulation/expectations were viewed.
2. Executive Director and/Or Clinical Supervisor will review all transfer charts prior to the patient dosing to ensure all transfer documents are completed, sent, and the proof uploaded to the chart. This is ongoing.
3. Executive Director and/or Clinical supervisor will conduct audits via Iauditor to ensure compliance with 715.20 is being met with all incoming and outgoing transfers. This is ongoing. |