INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 31-November 1, 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 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of nine personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #9 was hired on December 19, 2022 as a counselor assistant. Employee # 9 has a Bachelors degree with no experience and may counsel clients only under close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #9 did not receive formal case review during supervision occurring on February 3, 6, 13 and 20, 2023, March 7, 14, 21 and 31, 2023, April 3, 18 and 25. 2023, May 2, 9, 10, 16, 24 and 31, 2023, and June 26, 2023. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Based on a review of the supervision notes there is no documented formal case review for the first six months of employment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review and discuss with Executive Director the understanding of 704.8 and 704.9 in DDAP requirements involving a counselor assistant, and their supervision. At this time Charleroi Treatment Services do not have a counselor assistant to implement asap, however moving forward will be sure to add.
Action steps to plan: Executive Director will implement this documentation need 11/16/2023 and will review all supervision notes completed. Clinical Supervisor will ensure proper documentation is upheld, and review with Executive Director upon completion. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on May 31, 2023 and August 8, 2023 which involved death of a client. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This is a repeat citation from the February 24, 2023 licensing inspection.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
1.Executive Director will notify Regional Director when unusual incident had occurred within 24 hrs. of incident. Executive Director will submit unusual incident VIA Iris internal report for review and guidance of information given. 2.Executive Director will implement this to begin 11/16/2023 during individual supervision and provide training to Clinical Supervisor in the case if Executive Director is not available to complete. Internal approval from Medical Director, Regional Director, Coporate Compliance, QI prior to submittance to state. Executive Director will complete unusual incident within 3 days of incident, by completing online reporting system for DDAP. Executive Director will notify Clinical Supervisor incident report has been completed for additional confirmation that incident report has been completed. This will begin 11/16/2023, in the event an unusual incident would occur. |
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 provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in three out of five applicable records reviewed.
Patient #1 was admitted on May 9, 2023 and was still active at the time of the inspection. In July, the patient only received one hour of individual psychotherapy. In August and September of 2023, the patient only received 1.75 hours of psychotherapy each month.
Patient #2 was admitted on July 28, 2023 and was still active at the time of the inspection. In September 2023, the patient only received 49 minutes of psychotherapy.
Patient # 3 was admitted on May 31, 2023 and was still active at the time of the inspection. In June 2023, the patient only received two hours of psychotherapy. In July 2023, the patient only received 1.5 hours of psychotherapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Charleroi Clinical Supervisor and Executive Director reviewed requirements for counseling hours of patients in their first 2 years on 8/17/2023 and 10/19/2023 during monthly staff meeting. Executive Director will review again with staff members of requirements on 11/16/2023. Ongoing individual and group supervision will address progress in completion of counseling hours to meet DDAP standards and regulations. This individual and group supervision as well as ensuring POC is followed through will be the responsibility of the Executive Director and Clinical Supervisor.
Action steps and plan will include monthly individual supervision that will address counseling requirements met and barriers to meeting these requirements. Individual patient chars will be reviewed during specific individual supervision session and counseling requirements will be discussed. Education and training on time management and ensuring counseling requirements are met will be a part of group supervision and staff meetings. Counseling requirements will be reviewed and monitored with random chart audits completed and Executive Director and Clinical supervisor will address and issues with noncompliance in this area through continued training in clinical and staff meetings. |
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 the review of patient records, the facility failed to document an annual evaluation with all areas of regulation addressed within the regulatory timeframe in four out of four applicable records reviewed.
Patient # 4 was admitted on July 22, 2019 and was discharged on October 24, 2023. An annual evaluation was completed on June 29, 2022. The next annual evaluation was due no later than June 29, 2023; however, was completed on September 13, 2023.
Patient #5 was admitted on December 7, 2020 and was still active at the time of the inspection. An annual evaluation was due no later than December 7, 2023; however, it was completed on January 11, 2023.
Patient #6 was admitted on April 10, 2018 and was still active at the time of the inspection. An annual evaluation was due no later than April 10, 2023; however, it was completed on August 16, 2023.
Patient #8 was admitted on July 22, 2022 and discharged on October 13, 2023. An annual evaluation was due no later than July 22, 2023; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Charleroi Clinical Supervisor and Executive Director reviewed requirements for annual evaluations being completed on 8/17/2023 and 10/19/2023 during our monthly staff meeting. We will also review on 11/16/2023 in staff meeting as well. In addressing this area, all patients must have annual evaluations completed annually, no more than 365 days from the previous evaluation and 365 from intake. Ongoing individual and group supervision will address progress in completion of counseling hours to meet DDAP standards and regulations. This individual and group supervision as well as ensuring POC is followed through will be the responsibility of the Executive Director and Clinical Supervisor.
Action steps and plan will include monthly individual supervision that will address annual evaluation requirements met and barriers to meeting these requirements. Individual patient charts will be reviewed during specific individual supervision session and annual evaluations will be discussed. Education and training on time management and ensuring evaluations of all sorts are met will be a part of group supervision and staff meetings. Annual Evaluations will be reviewed and monitored with random chart audits completed and Executive Director and Clinical supervisor will address and issues with noncompliance in this area through continued training in clinical and staff meetings. |
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 that a comprehensive treatment plan was developed with the client per facility ' s policy and procedure manual within 30 days of admission in two out of four applicable records reviewed.
Client #1 was admitted on May 9, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 9, 2023; however, it was completed on June 24, 2023.
Client #2 was admitted on July 28, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 28, 2023; however, it was completed on October 4, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Charleroi Clinical Supervisor and Executive Director reviewed requirements for Comprehensive treatment plans being completed on 8/17/2023 and 10/19/2023 during our monthly staff meeting. We will also review on 11/16/2023 in staff meeting as well. In addressing this area, all patients must have comprehensive treatment plans completed within the first 30 days of intake. Ongoing individual and group supervision will address progress in completion of Comprehensive treatment plans to meet DDAP standards and regulations. This individual and group supervision as well as ensuring POC is followed through will be the responsibility of the Executive Director and Clinical Supervisor.
Action steps and plan will include monthly individual supervision that will address comprehensive treatment plan requirements met, and barriers to meeting these requirements. Individual patient charts will be reviewed during specific individual supervision session and annual evaluations will be discussed. Education and training on time management and ensuring comprehensive treatment plans and treatment plan updates are met will be a part of group supervision and staff meetings. Treatment plans will be reviewed and monitored with random chart audits, along with review of audits within IAuditor. Executive Director and Clinical supervisor will address issues with noncompliance in this area through continued training in clinical and staff meetings. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of eight records reviewed.
Client #1 was admitted on May 9, 2023 and was still active at the time of the inspection. A treatment plan update was completed on August 2, 2023, and the next update was due no later than October 2, 2023; however, it was completed on October 10, 2023.
Client #5 was admitted on December 7, 2020 and was still active at the time of the inspection. A treatment plan update was completed on June 26, 2023, and the next update was due no later than August 26, 2023; however, it was completed on September 12, 2023.
Client #8 was admitted on July 22, 2022 and discharged on October 13, 2023. A treatment plan update was completed on February 10, 2023, and the next update was due no later than April 10, 2023; however, it was completed on May 31, 2023. The next treatment plan update was due no later than July 31, 2023; however, it was completed on August 8, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Charleroi Clinical Supervisor and Executive Director reviewed requirements for treatment plan updates being completed on 8/17/2023 and 10/19/2023 during our monthly staff meeting. We will also review on 11/16/2023 in staff meeting as well. In addressing this area, all patients must have treatment plans completed within 60 days of the previous update. Ongoing individual and group supervision will address progress in completion of treatment plan updates to meet DDAP standards and regulations. This individual and group supervision as well as ensuring POC is followed through will be the responsibility of the Executive Director and Clinical Supervisor.
Action steps and plan will include monthly individual supervision that will address treatment plan update requirements met, and barriers to meeting these requirements. Individual patient charts will be reviewed during specific individual supervision session and treatment plan updates will be discussed. Education and training on time management and ensuring treatment plans updates are met will be a part of group supervision and staff meetings. Treatment plans will be reviewed and monitored with random chart audits, along with review of audits within IAuditor. Executive Director and Clinical supervisor will address issues with noncompliance in this area through continued training in clinical and staff meetings. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of eight applicable records reviewed.
Client #1 was admitted on May 9, 2023 and was still active at the time of the inspection. A comprehensive treatment plan dated June 24, 2023 indicated 2.5 hours of psychotherapy a month. In July 2023, the client only received one hour of psychotherapy. In August and September of 2023, the client only received 1.75 hours of psychotherapy each month.
Client #2 was admitted on July 28, 2023 and was still active at the time of the inspection. A treatment plan dated July 28, 2023 indicated 2.5 hours of psychotherapy a month. In August 2023, the client only received 1.5 hours of psychotherapy. In September 2023, the client only received 49 minutes of psychotherapy.
Client # 3 was admitted on May 31, 2023 and was still active at the time of the inspection. A treatment plan dated June 29, 2023 indicated 2.5 hours of psychotherapy a month. In July 2023, the client only received 1.5 hours of psychotherapy.
Client #5 was admitted on December 7, 2020 and was still active at the time of the inspection. The treatment plan dated May 1, 2023 indicated 30-45 minutes of psychotherapy a week. In June and July 2023, the client did not receive any psychotherapy.
Client #6 was admitted on April 10, 2018 and was still active at the time of the inspection. The treatment plan dated May 20, 2023 indicated 30 minutes of psychotherapy a month. In July 2023, the client did not receive any psychotherapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Charleroi Clinical Supervisor and Executive Director reviewed what requirements are needed per patient, and what was written within the treatment plan to be reflected by case notes in Methasoft. This was all addressed 10/19/2023 during our monthly staff meeting. We will also review on 11/16/2023 in staff meeting as well. In addressing this area, all staff must complete units mentioned within the treatment plan objectives. Ongoing individual and group supervision will address progress in completion of treatment plan updates to meet DDAP standards and regulations. This individual and group supervision as well as ensuring POC is followed through will be the responsibility of the Executive Director and Clinical Supervisor.
Action steps and plan will include monthly individual supervision that will address units needed per caseload, per patient and barriers to meeting these requirements. Individual patient charts will be reviewed during specific individual supervision session and treatment plan interventions will be discussed. Education and training on time management and ensuring unit requirements are accurate and being completed. Treatment plan interventions will be reviewed and monitored with random chart audits, along with review of audits within IAuditor. Executive Director and Clinical supervisor will address issues with noncompliance in this area through continued training in clinical and staff meetings. |