INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 5-6, 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 Center PA-VI, LLC dba Greenfield Counseling 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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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two of six client records.
Client #3 was admitted on March 9, 2022 and is currently active. There was no psychosocial evaluation documented in client record #3.
Client #6 was admitted on November 16, 2021 and is currently active. There was no psychosocial evaluation documented in client record #6.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Client #3 engaged in active avoidance of completing the Bio. They were a transfer patient and expressed that they did not see a reason to re-complete the bio with this facility. It was completed after they were threatened with loss of THB for non-compliance. The counselor assigned to Client #3 is a recent hire and has now been trained on firmer boundaries with patients and engaging the clinical supervisor immediately when encountering resistance to meeting requirements.
The bio for Client #6 was to be completed by the primary assigned counselor within the first few days of treatment due to patient presentation at intake. They failed to do so. They have since left employment and the newly assigned counselor failed to review the chart fully. This bio has since been completed.
The necessity to review all charts when assigned a new patient was reviewed with all clinical staff during April 2022 individual supervision by the facility Executive Director. In addition, a documentation process for verifying completion and review of patient charts upon assignment/re-assignment to a counselor has been implemented and this documentation is part of the patient chart. This documentation will be reviewed by the Executive Director and as part of the facility's internal chart review process and as part of the company's QI chart review process.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document quarterly case consultations, as per agency policy, in three of ten client records.
Client #1 was admitted on July 28, 2021 and is currently an active client. Case consultations were due to be completed by October 28, 2021 and January 28, 2022. There were no case consultations documented in client record #1.
Client #9 was admitted on September 15, 2020 and discharged on September 3, 2021. There were no case consultations documented in 2021.
Client #11 was admitted on December 27, 2019 and discharged on October 14, 2021. There were no case consultations documented in client record #11.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All charts noted were under a single counselor who is no longer employed with the facility, therefore retraining of this individual is not possible. A review of charting guidelines was conducted with all staff during April 2022 individual supervisions. ED will continue to monitor compliance monthly. |
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 client records, the facility failed to document follow up contact, 30 and 90 days post discharge, per agency policy, in three of three client records.
Client #8 was admitted on February 18, 2016 and discharged on November 12, 2021. Follow up contact was due by December 12, 2021 and February 12, 2022. There was no follow up contact documented in client record #8.
Client #9 was admitted on September 20, 2020 and discharged on September 3, 2021. Follow up contact was due by October 3, 2021 and December 3, 2021. There was no follow up contact documented in client record #9.
Client #10 was admitted on February 3, 2021 and discharged on February 1, 2022. Follow up contact was due by March 1, 2022. There was no follow up contact documented in client record #10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All charts noted were from two staff members. Upon review it was determined that these staff were not properly tracking reminders built into the EHR and therefore missing reminders to conduct follow-ups. They have been retrained and have reached out and attempted follow-ups with the patients. Additionally, follow-ups were included as part of the charting guidelines review conducted during April 2022 individual supervision will all clinical staff. ED will continue to monitor compliance monthly. |