INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 10-11, 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-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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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to provide documentation of inspection of storage areas that ensures compliance with state and federals and program policy.
The facility ' s policy and procedure manual states the inspection of storage areas should be done quarterly. The inspection log contained documentation that the drug storage area was inspected October 11, 2023. The next inspection was due no later than January 11, 2024. The next documented inspection was performed July 30, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director provided education on the expectation that the medical room review take place quarterly (every 3 months) and that the next inspection is due. Staff responsible LPN.
1. LPNs (2) will alternate who will complete the quarterly inspections to ensure that they are being completed in a timely manner to share the responsibility.
2. Executive Director will confirm that inspections are completed and sign off each quarter. |
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 one of five applicable records.
Patient # 3 was admitted on February 27, 2024 to the outpatient level of care and was still active at the time of the inspection. In May 2024, the patient received 45 minutes of psychotherapy. In June 2024, the patient received 9 minutes of psychotherapy. In July 2024, the patient received 13 minutes of psychotherapy. In August 2024, the patient received 11 minutes of psychotherapy.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 15, 2023 licensing inspection.
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Plan of Correction
Training and Education:
1. ED and Clinical supervisor reviewed the expectation of counseling requirements of patients which are to have 2.5 hour of counseling per month on 9/12/24.
2. ED and clinical supervisor reviewed with clinical staff the expectation of counseling requirements of patients which have 2.5 hours of counseling at staff meeting on 9/16/24.
3. Ongoing individual and group supervision as well as ensuring POC is followed will be monitored by Executive Director, Clinical Supervisor, and Lead Counselor as appropriate.
Action Steps/ Plan:
1. Supervisory staff and view review counseling requirements in clinical group and staff meetings.
2. Monthly individual supervision will address counseling requirements and include discussion related to requirements met and barriers to meeting requirements.
3. Clinical staff will document scheduled sessions in DAP notes in compliance with Pinnacle policy as well as any cancelled or missed sessions.
4. Individual patient charts will be reviewed during specific individual supervision sessions.
5. Counseling requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 one hour every other month of psychotherapy after four years of treatment in one of one applicable record.
Patient #2 was admitted on April 6, 2015 to the outpatient level of care and was active at the time of review. In April 2024, the patient received 30 minutes of psychotherapy. Patient #2 received no psychotherapy in May, June, and July 2024. In August 2024, the patient received 30 minutes of psychotherapy.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the November 15, 2023 licensing inspection.
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Plan of Correction
Training and Education:
1. ED and Clinical supervisor reviewed the expectation of counseling requirements of patients which are to have 1 hour of counseling every other month on 9/12/24.
2. ED and clinical supervisor reviewed with clinical staff the expectation of counseling requirements of patients which have 1 hour every other month of counseling at staff meeting on 9/16/24.
3. Ongoing individual and group supervision as well as ensuring POC is followed will be monitored by Executive Director, Clinical Supervisor, and Lead Counselor as appropriate.
Action Steps/ Plan
1. Supervisory staff and view review counseling requirements in clinical group and staff meetings.
2. Monthly individual supervision will address counseling requirements and include discussion related to requirements met and barriers to meeting requirements.
3. Clinical staff will document scheduled sessions in DAP notes in compliance with Pinnacle policy as well as any cancelled or missed sessions.
4. Individual patient charts will be reviewed during specific individual supervision sessions.
5. Counseling requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document transfer of patient files to the patient's new treatment facility in one of two applicable record.
Patient #6 was admitted on March 1, 2023 to the outpatient level of care and transferred to another facility on June 14, 2024. At the time of the inspection, there was no documentation that facility transferred patient files to the new facility.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training and Education:
1. ED reviewed transfers with clinical supervisor, clinical staff, and medical staff in staff meeting on 9/16/24 including faxing/ scanning the fax confirmation into Methasoft to provide evidence of what documents were sent as well as the confirmation page.
2. ED provide a transfer out checklist page and review procedure and policy with all staff by 10/28/24.
Action Steps/ Plan:
When the facility has prior notification that a patient is transferring to another facility, counselors will meet with the patient to complete the releases and follow the checklist to send information to the transfer facility.
After documents are sent, counselors/ clinical staff will scan the documents with the fax confirmation into Methasoft.
Counselor will submit the checklist with patient number to supervisory staff for review with in 24 hours of transmission of documents.
Medical staff (LPNs/ Physician's Assistant) will confirm last dose date and amount as appropriate and document the information in Methasoft in compliance with Pinnacle Policy. |
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 in one of three applicable records.
Patient #3 was transferred to the facility and admitted to the outpatient level of care on February 27, 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training and Education:
1. Executive Director reviewed transfers with clinical supervisor, clinical staff, and medical staff in staff meeting on 9/16/24 including faxing/ scanning the fax confirmation into Methasoft to provide evidence of what documents were sent as well as the confirmation page.
2. Executive Director provide a transfer in checklist page and review procedure and policy with all staff by 10/28/24.
Action Steps/ Plan:
When a patient is transferring into the facility, a release of information with be signed with the new patient. If the identified information has not yet been received, counselor will fax the release and a request for transfer in documents and follow up with the sending facility with a phone call if records are not received.
Counselor/ receiving staff will obtain the documents and scan all information received into Methasoft in compliance with Pinnacle policy/ state regulations.
Supervisory staff and medical staff will review received documents.
Executive director and clinical supervisor will ensure that written notification of transfer is completed and sent at the completion for all patients who are transferring in. |
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 three of three applicable records.
Client #3 was admitted on February 27, 2024 to the outpatient level of care and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 27, 2024; however, it was completed on May 22, 2024.
Client #4 was admitted on July 30, 2024 to the outpatient level of care and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 30, 2024; however, it was completed on September 9, 2024.
Client #5 was admitted on April 15, 2024 to the outpatient level of care and was discharged August 27, 2024. A comprehensive treatment plan was due no later than May 15, 2024; however, it was completed on May 29, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 15, 2023 licensing inspection.
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Plan of Correction
Training and Education:
1. ED reviewed expectation for initial/ intake treatment plan in staff meeting on 9/16/24.
2. ED will develop a revised intake checklist for staff to use in order to track completion of intake documents by 11/15/24 and provide updates as needed.
Action Steps/ Plan:
1. Supervisory Staff will review requirements for completion of the intake treatment plan within compliance with Pinnacle policy and procedure within the first 7 days of the patient entering treatment.
2. Supervisory staff will check new admission in Methasoft for all patients to verify that the intake treatment plan has been completed.
3. Supervisory staff will continue to review regulations around intake treatment plans related to education and training on timely completion in staff meetings, as well as individual and group clinical supervisions.
4. Supervisory staff will use tracking system (Tableau) to track treatment plan completion as well as provide feedback related to when treatment plans are due, missing, or late. |
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 of six applicable records.
Client #2 was admitted on April 6, 2015 to the outpatient level of care and was still active at the time of the inspection. A treatment plan was completed on February 13, 2024. The next update was due no later than April 13, 2024; however, it was completed on June 25, 2024.
Client #6 was admitted on March 1, 2023 to the outpatient level of care and was discharged June 14, 2024. A treatment plan was completed on March 7, 2024. The next update was due no later than May 7, 2024; however, it was completed on May 30, 2024.
Client #8 was admitted on December 28, 2021 to the outpatient level of care and was discharged April 12, 2024. A treatment was completed on January 16, 2024. The next update was due no later than March 16, 2024; however, no further updates were completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 15, 2023 licensing inspection.
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Plan of Correction
Training and Education:
1. ED and clinical supervisor reviewed the expectation and regulation for comprehensive treatment plans and reviews (every 60 days) in staff meeting on 9/16/24.
2. Clinical supervisor reviews expectation of treatment plan updates and revisions weekly at staff meeting and distributes lists of past due and upcoming treatment plans on a weekly basis.
Action Steps and Plan:
1.Supervisory staff will continue to review regulations related to comprehensive treatment plans and education on timely completion of comprehensive treatment plans in clinical group and individual supervisions.
2. Supervisory staff will review treatment plan compliance in scheduled events in Methasoft and correct inaccurate dates as well as track compliance in Tableau weekly.
3. Supervisory staff with provided lists of past due, pending, and upcoming treatment plan updates to counseling staff to assist with tracking.
4. Supervisory staff will double check for treatment plan compliance and review any barriers to meeting facility policy and procedure. |
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 provide a complete client record, which is to include follow-up information in one out of one applicable record reviewed.
Facility policy and procedure states that follow-up information will be obtained seven days, 30 days, and 60 days following discharge.
Client #8 was admitted on December 28, 2021 and was discharged on April 12, 2024. A follow up was due no later than April 19, 2024; however, no follow-up was documented.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the November 15, 2023 licensing inspection.
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Plan of Correction
Training and Education:
1. ED and clinical supervisor reviewed the expectation for completing follow up phone calls (7, 30, & 60)
2. ED developed a spreadsheet to track discharge follow up call due dates and completion.
3. Clinical supervisor calls discharged patients and maintain the spreadsheet.
Action Steps/ Plan:
1. When a patient is discharged from the facility, clinical supervisor records the patient information including discharge date and the corresponding dates for the 3 discharge follow up calls into the excel spreadsheet.
2. Clinical supervisor reviews the spreadsheet weekly and calls all patients who are due for discharge follow ups, completes the follow assessment in Methasoft and records the completed calls in the spreadsheet to ensure that all discharge follow up calls are made.
3. ED reviews that discharge assessment report in Methasoft on a weekly basis to ensure that calls are being completed as scheduled. |