INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on January 10 and January 23, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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709.33 (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
The facility failed to document, in writing, the decision to involuntarily terminate the client's treatment at the project including the reason for termination in two of two client records reviewed on January 10 and January 23, 2019.
Client # 3 was admitted September 21, 2015 and involuntarily terminated on August 30, 2018.
Client # 9 was admitted April 7, 2015 and involuntarily terminated on October 2, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold a staff meeting, prior to 2/8/19 on utilization of the form "Administrative Discharge Notification". The form notifies patients of the decision to involuntarily terminate and reason for termination. Staff will utilize this form when an involuntary termination is to occur. The facility director will ensure the form is completed prior to discharge of the 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
The facility failed to 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 in two of two patient records reviewed on January 23, 2019.
Patient # 6 transferred into the facility on June 5, 2018.
Patient # 7 transferred into the facility on May 15, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold a staff meeting prior to 2/8/19, reviewing the policy for notifying the transferring clinics of admission of the patient and date of intake/initial dose. The clinical supervisor will monitor this on the intake checklist and during monthly chart reviews. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The facility failed to document a preliminary treatment plan in two of four client records reviewed on January 10 and January 23, 2019.
Client # 1 was admitted September 25, 2018.
Client # 7 was admitted May 15, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will create an intake checklist for counselors, prior to 2/8/2019. The checklist will be reviewed during a staff meeting. The checklist will ensure that each patient completes a preliminary treatment plan during the intake process. The clinical supervisor will ensure that this occurs at the end of scheduled intake days. |