INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Pinnacle Treatment Centers 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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715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records, the facility failed to document verification that the client reached 18 years of age.Client #6 was admitted on January 23, 2020 and discharged on September 25, 2020. There was no identification or age verification documented in client record #6.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document verification that all reviewed clients reached 18 years of age.
Facility will make sure all admission ID verifications are received to verify the individual has reached the age of 18 and scanned into the electronic medical records.
Supervisory staff will monitor this process and continue to conducted admission chart reviews which does include this aspect of the patient file.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to document verification of the client's identity including name, address, date of birth, emergency contact and other identifying data.Client #6 was admitted on January 23, 2020 and discharged on September 25, 2020. There was no documentation of verification of the client's identity including name, address, date of birth, emergency contact and other identifying data.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document verification of the client's identity including name, address, date of birth, emergency contact and other identifying data during admission.
Facility will make sure all admission ID verifications are received to verify the individual' identity and scanned into the electronic medical records.
Supervisory staff will monitor this process and continue to conducted admission chart reviews which does include this aspect of the patient file.
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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 client records, the faciltiy failed to document that each client was provided with an average of at least 2.5 hours per month.Client #5 was admitted on February 28, 2020 and is currently an active client. The last therapy session that was documented was on August 26, 2020. There were no sessions documented in September, October, November, December 2020 as well as January, February and March 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for all patient records that were reviewed.
The facility will ensure that all patients receive the required of monthly psychotherapy. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to when other staff are out of the building.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Facility Staff will utilize Electronic Record reports to periodically check counseling compliance for their caseloads.
Supervisory staff will continue to conducted weekly chart reviews which does include this aspect of the patient file.
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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 client records, the facility failed to document that client files were transferred to the receiving facility in one of one client records.Client #4 was admitted on February 11, 2020 and transferred out to another facility on June 8, 2020. There was no documentation that information was sent to the receiving facility in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide all the required documentation upon patients transfer to another narcotic treatment program.
The facility will ensure that all patients required documentation is provided to transferring narcotic treatment program when appropriate and with signed ROIs. The transferred documentation will also be imported into the electronic medical record.
When the facility has prior knowledge of potential patient transfers patient releases/consents will be completed in preparation to send required transfer documents.
However, if prior release/consents have not been completed the facility will only transfer documents covered under the release/consent provided by the transferring facility.
Facility started utilizing a new EMR as of September 2020 which provides an easier process to import external documentation into the system.
Supervisory staff will monitor this process and continue to conducted weekly chart reviews which does include this aspect of the patient file.
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