INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 27, 2022 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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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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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. Plans of correction for providing each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years were submitted and approved by the Department for the September 16, 2021, April 23, 2021 and October 25, 2019 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility had a reoccurring deficiency for failure to provide 2.5 hours of psychotherapy services for individuals being served.
During 2023 budgeting process, Cooperate staff will review current staffing patterns/data points and will make needed changes to help recruit and hire needed facility staff.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to help ease load when other staff are out of the building.
Facility will return to pre-Covid group implementation and return to a treatment recommendation that includes a mix between individual and group clinical services.
Supervisory staff will retrain clinical staff on the appropriate way to document missed sessions and when patients have continued issues with session compliance.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs. Supervisory staff will work with struggling clinical staff to develop strategies around resolving clinical compliance and time management issues.
Supervisory staff will conduct spot checks during clinical supervision specifically around patient clinical compliance. Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
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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 two of five applicable patient records reviewed, the facility failed to provide documentation of a narcotic treatment program providing each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years.Patient # 2 was admitted on April 18, 2022 and was still active at the time of the inspection. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of: April 18- May 17- 0May 18- June 17- 65 minutesPatient # 3 was admitted on April 13, 2022 and was still active at the time of the inspection. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of April 13 through September 12, 2022. there were no progress notes indicating any therapy sessions. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 16, 2021, April 23, 2021 and October 25, 2019 annual licensing inspection.
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Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for two of the reviewed charts.
The facility will ensure that all patients receive the required monthly psychotherapy hours. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Facility will return to pre-Covid group implementation and return to a treatment recommendation that includes a mix between individual and group clinical services.
Supervisory staff will retrain clinical staff on the appropriate way to document missed sessions and when patients have continued issues with session compliance.
Clinical Supervisor staff will have all clinical staff print out clinical compliance reports from the EMR and turn in week to check session compliance.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to help ease load when other staff are out of the building.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
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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 one of one applicable patient records reviewed, the facility failed to provide documentation of a narcotic treatment program providing each patient an average of 1 hour of psychotherapy per month for the patients third and fourth year of treatment.Patient # 1 was admitted on February 5, 2019 and was still active at the time of the inspection. A review of progress notes indicates the patient did not receive 1 hour of psychotherapy per month. For the month of July, 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 16, 2021 annual licensing inspection.
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Plan of Correction
The facility failed to provide 1 hour of psychotherapy services for one of the reviewed charts.
The facility will ensure that all patients receive the required of monthly psychotherapy. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Clinical Supervisor staff will have all clinical staff print out clinical compliance reports from the EMR and turn in week to check session compliance.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to help ease load when other staff are out of the building.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
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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 two of five applicable patient records reviewed, the facility failed to provide documentation of an annual evaluation of the patient's status being completed by the patient 's counselor and shall also be reviewed, dated and signed by the medical director.Patient # 1 was admitted on February 5, 2019 and was still active at the time of the inspection. There was no annual evaluation in the patient record and was due no later than February 2, 2022.Patient # 8 was admitted on November 20, 2020 and was discharged June 22, 2022. There was no annual evaluation in the patient record and was due no later than November 20, 2021.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 16, 2021 annual licensing inspection.
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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 chart.
The facility will ensure that all required annual documentation is completed as required by regulations and clinical staff will keep a secondary tracking system to monitor compliance which is shared and monitored by supervisory staff.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to required clinical annual documentation.
Open counseling positions will be filled to help ease the burden on current counseling staff and to make sure patient required documentation does not get missed.
Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
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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 two of four applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow up is to occur within 7 days, 3 months, and 12 months of the patient discharge. A follow-up will occur within 1 week of discharge if the patient is referred to another agency. Client # 5 was admitted on February 21, 2020 and was discharged on March 22, 2022. There was no follow-up information documented in the patient record.Client # 6 was admitted on February 11, 2022 and was discharged on June 1, 2021. There was no follow-up information documented in the patient record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 16, 2021 annual licensing inspection.
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Plan of Correction
The facility failed to appropriately document discharge follow-ups in two record that was reviewed.
A new external tracking system has been implemented outside the current EMR to report and monitor completion of patient discharge follow-ups and facility will ensure that all clinical staff are appropriately trained on required discharge follow-up documentation.
The facility will ensure that all required discharge follow-ups are completed per facility policies/procedure manual.
Supervisory Staff will meet with program staff in treatment team meeting and review all requirements related to scheduling & completion of discharge follow-ups.
Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
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