INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 15-16, 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 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit heaters that are not permanently mounted or installed.
A portable heater was observed in a counseling office during the physical plant inspection conducted on February 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-ED confirmed that there were no other space heaters in the building and that the noted space heater was removed -2/17/23
-ED reviewed with all staff policies banning space heaters via all staff (Teams) message 2/16/23. Policy was also reviewed with all staff during staff meeting -Completed 2/23/23
-ED will explore options for re-insulating the office in question, as it can significantly cooler in winter than the rest of the building - December 2023 |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to file a written incident report with DDAP, within 3 business days, regarding an event at the facility requiring the presence of police, fire or ambulance personnel.
During client record review, a note was reviewed stating an incident with client #7 occurred on June 14, 2022 requiring a call to the police and ambulance. There was no documentation this event was reported to DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-All required reports will be submitted to the ERS within the required timeframe on an ongoing basis
-ED will verify and download copies of all submitted reports both prior to acceptance as well as verify acceptance on an ongoing basis. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to document the physician's basis for the determination of current dependency and evidence of a 1-year history of addiction in one of six patient records.
Patient #2 was admitted on May 4, 2022 and is currently an active patient. There was no documentation of physician determination of current dependency and evidence of 1 year history of addiction in patient record #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
-Physician will appropriately and correctly document current signs/symptoms of addiction during intake -Ongoing
-Physician will appropriately and correctly document an at least 1 year history of sign/symptoms of addiction during intake - Ongoing
-ED or designate will review physician documentation of intake upon completion - Ongoing
-ED, Lead Counselor, and QI will perform regular chart audits that will include intake documentation - Ongoing |