INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 24-25, 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-VIII, 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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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 three of four applicable records
Patient #1 was admitted to the outpatient level of care on September 26, 2022 and was active at the time of review. Patient #1 had only .5 hours of psychotherapy during the month of March 2024, 1.25 hours of psychotherapy during the month of April 2024, and 1.25 hours of psychotherapy during the month of May 2024.
Patient #2 was admitted to the outpatient level of care on April 18, 2024 and was active at the time of review. Patient #2 had only 1 hour of psychotherapy during the month of July 2024.
Patient #7 was admitted to the outpatient level of care on June 21, 2024 and was active at the time of review. Patient #7 had only 1.25 hours of psychotherapy during the month of July 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 1, 2023 licensing inspection.
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Plan of Correction
Education and Training efforts will be provided to Clinicians by Executive Director/Clinical Regional Clinical Supervisor/and Clinical Supervisor to address counseling requirements not being met per regulations. Education and training efforts will also focus on time management.
Action steps included providing the above training and education via Relias, individual supervision and direct observation as well as administration meetings and group clinical supervision. Administrative meetings to be held monthly and clinical supervision to be held on a weekly basis throughout the month of November to address the noted recommendations, areas of opportunity and improvements. Counselors will schedule a minimum of 5 hours of counseling each day and increase scheduling as needed to meet face-to-face daily service requirements. Counselors to utilize Methasoft scheduler to record all clinic activity and counseling sessions. At the conclusion of sessions, patients will be scheduled for the next session and flags placed within the EMR. Counselors will attempt to length session duration. Example ? If a patient usually stays for 30 minutes, attempt to have them stay an additional 15 minutes. Supervisor/Director will meet with counselor weekly to review scheduler, services due, documentation completions, and current face-to-face %. Supervisor will review the counselor's schedule daily and schedule additional sessions to fill open spots in the counselor's schedule. Patients will be flagged by the Supervisor to attend or schedule counseling for the week. Clinical Supervisor will be trained on how to utilize iAuditor for accountability/follow up/review Regional Director and Executive director to review monitoring reports during weekly regional calls Quality improvement to complete chart audits for training purposes and review expectations for each indicator per quarter. Clinical staff meeting reviewed DDAP recommendations on 10/2/2024. Will address above education and training opportunities on the following dates: November 6, 2024; November 13, 2024. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 each patient at least one hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of two applicable records.
Patient #6 was admitted to the outpatient level of care on August 16, 2021 and was active at the time of review. Patient #6 had only .5 hours of psychotherapy during the month of May 2024, .75 hours of psychotherapy during the month of July 2024, and .5 hours of psychotherapy during the month of August 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Education and Training efforts will be provided to Clinicians by Executive Director/Clinical Regional Clinical Supervisor/and Clinical Supervisor to address counseling requirements not being met per regulations. Education and training efforts will also focus on time management.
Action steps included providing the above training and education via Relias, individual supervision and direct observation as well as administration meetings and group clinical supervision. Administrative meetings to be held monthly and clinical supervision to be held on a weekly basis throughout the month of November to address the noted recommendations, areas of opportunity and improvements. Counselors will schedule a minimum of 5 hours of counseling each day and increase scheduling as needed to meet face-to-face daily service requirements. Counselors to utilize Methasoft scheduler to record all clinic activity and counseling sessions. At the conclusion of sessions, patients will be scheduled for the next session and flags placed within the EMR. Counselors will attempt to length session duration. Example ? If a patient usually stays for 30 minutes, attempt to have them stay an additional 15 minutes. Supervisor/Director will meet with counselor weekly to review scheduler, services due, documentation completions, and current face-to-face %. Supervisor will review the counselor's schedule daily and schedule additional sessions to fill open spots in the counselor's schedule. Patients will be flagged by the Supervisor to attend or schedule counseling for the week. Clinical Supervisor will be trained on how to utilize iAuditor for accountability/follow up/review Regional Director and Executive director to review monitoring reports during weekly regional calls Quality improvement to complete chart audits for training purposes and review expectations for each indicator per quarter. Clinical staff meeting reviewed DDAP recommendations on 10/2/2024. Will address above education and training opportunities on the following dates: November 6, 2024; November 13, 2024. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual evaluation of each patient ' s status, completed by the patient ' s counselor and reviewed, dated, and signed by the medical director in one of three applicable records.
Patient #6 was admitted to the outpatient level of care on August 16, 2021 and was active at the time of review. An annual evaluation was due for patient #6 no later than August 16, 2024. No evaluation for 2024 was found in the patient ' s record.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the November 1, 2023 licensing inspection.
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Plan of Correction
Supervision to further focus on completing services on time per regulatory time frames. Executive Director, Regional Clinical Supervisor and Clinical Supervisor will develop and provide education to clinicians on self-monitoring, time management, and expectations regarding regulatory charting time frames. Will provide re training for clinical staff on how to edit and individualize treatment plans in EHR and how to implement the initial treatment plan template into the comprehensive treatment plan and treatment plan updates rather than using a form. Training will also be provided via Relias, chart audit reviews and reviews of collected data from Tableau and SharePoint. Action steps included providing the above training and education via Relias, individual supervision and direct observation as well as administration meetings and group clinical supervision. Administrative meetings to be held monthly and clinical supervision to be held on a weekly basis throughout the month of November to address the noted recommendations, areas of opportunity and improvements.
Counselors to maintain 95% of all patient service documentation (i.e., case notes, progress notes, intake notes, case management notes, etc. and excluding assessments, treatment plans, and other documents that may take more than 1 session to complete) in the Electronic Health Record, within 24- hours of provided service.
Counselors will complete and sign session notes within 24 hours of session, this includes encounter forms.
Counselors will document all missed sessions (rescheduled, no show for session, group, etc.)
Supervisor/Director will meet with counselor weekly to review scheduler, services due, documentation completions, and current face-to-face %. Supervisor will review the counselor's schedule daily and schedule additional sessions to fill open spots in the counselor's schedule. Patients will be flagged by the Supervisor to attend or schedule counseling for the week.
Clinical Supervisor will be trained on how to utilize iAuditor for accountability/follow up/review Clinical supervisor will review signature reports via EHR and tableau, including various dashboards including treatment planning. Clinical Supervisor will provide a list of weekly and monthly treatment plans due to counselors to complete on a weekly basis.
Regional Director and Executive director to review monitoring reports during weekly regional calls Quality improvement to complete chart audits for training purposes and review expectations for each indicator per quarter.
Clinical staff meeting reviewed DDAP recommendations on 10/2/2024. Will address above education and training opportunities on the following dates: November 20, 2024 and November 27, 2024. |
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 two of three applicable records.
Client #7 was admitted on June 21, 2024 to the outpatient level of care and was active at the time of review. A comprehensive treatment plan was due no later than July 21, 2024; however, it was completed on September 10, 2024.
Client #8 was admitted on April 17, 2024 to the outpatient level of care and was discharged June 20, 2024. A comprehensive treatment plan was due no later than May 17, 2024; however, it was completed on May 24, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 1, 2023 licensing inspection.
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Plan of Correction
Supervision to further focus on completing services on time per regulatory time frames. Executive Director, Regional Clinical Supervisor and Clinical Supervisor will develop and provide education to clinicians on self-monitoring, time management, and expectations regarding regulatory charting time frames. Will provide re training for clinical staff on how to edit and individualize treatment plans in EHR and how to implement the initial treatment plan template into the comprehensive treatment plan and treatment plan updates rather than using a form. Training will also be provided via Relias, chart audit reviews and reviews of collected data from Tableau and SharePoint. Action steps included providing the above training and education via Relias, individual supervision and direct observation as well as administration meetings and group clinical supervision. Administrative meetings to be held monthly and clinical supervision to be held on a weekly basis throughout the month of November to address the noted recommendations, areas of opportunity and improvements.
Counselors to maintain 95% of all patient service documentation (i.e., case notes, progress notes, intake notes, case management notes, etc. and excluding assessments, treatment plans, and other documents that may take more than 1 session to complete) in the Electronic Health Record, within 24- hours of provided service.
Counselors will complete and sign session notes within 24 hours of session, this includes encounter forms.
Counselors will document all missed sessions (rescheduled, no show for session, group, etc.)
Supervisor/Director will meet with counselor weekly to review scheduler, services due, documentation completions, and current face-to-face %. Supervisor will review the counselor's schedule daily and schedule additional sessions to fill open spots in the counselor's schedule. Patients will be flagged by the Supervisor to attend or schedule counseling for the week.
Clinical Supervisor will be trained on how to utilize iAuditor for accountability/follow up/review Clinical supervisor will review signature reports via EHR and tableau, including various dashboards including treatment planning. Clinical Supervisor will provide a list of weekly and monthly treatment plans due to counselors to complete on a weekly basis.
Regional Director and Executive director to review monitoring reports during weekly regional calls Quality improvement to complete chart audits for training purposes and review expectations for each indicator per quarter.
Clinical staff meeting reviewed DDAP recommendations on 10/2/2024. Will address above education and training opportunities on the following dates: November 20, 2024 and November 27, 2024. |
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 #4 was admitted on November 20, 2018 to the outpatient level of care and was discharged May 29, 2024. A treatment plan was completed on December 7, 2023. The next update was due no later than February 7, 2024; however, it was completed on April 11, 2024.
Client #5 was admitted on September 20, 2021 to the outpatient level of care and was active at the time of review. A treatment plan was completed on June 4, 2024. The next update was due no later than August 4, 2024; however, it was completed on August 7, 2024.
Patient #6 was admitted to the outpatient level of care on August 16, 2021 and was active at the time of review. A treatment plan was completed on April 26, 2024. The next update was due no later than June 26, 2024; however, it was completed on July 19, 2024. The next treatment plan update was due no later than September 19, 2024; however, it was completed September 24, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 1, 2023 licensing inspection.
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Plan of Correction
Supervision to further focus on completing services on time per regulatory time frames. Executive Director, Regional Clinical Supervisor and Clinical Supervisor will develop and provide education to clinicians on self-monitoring, time management, and expectations regarding regulatory charting time frames. Will provide re training for clinical staff on how to edit and individualize treatment plans in EHR and how to implement the initial treatment plan template into the comprehensive treatment plan and treatment plan updates rather than using a form. Training will also be provided via Relias, chart audit reviews and reviews of collected data from Tableau and SharePoint. Action steps included providing the above training and education via Relias, individual supervision and direct observation as well as administration meetings and group clinical supervision. Administrative meetings to be held monthly and clinical supervision to be held on a weekly basis throughout the month of November to address the noted recommendations, areas of opportunity and improvements.
Counselors to maintain 95% of all patient service documentation (i.e., case notes, progress notes, intake notes, case management notes, etc. and excluding assessments, treatment plans, and other documents that may take more than 1 session to complete) in the Electronic Health Record, within 24- hours of provided service.
Counselors will complete and sign session notes within 24 hours of session, this includes encounter forms.
Counselors will document all missed sessions (rescheduled, no show for session, group, etc.)
Supervisor/Director will meet with counselor weekly to review scheduler, services due, documentation completions, and current face-to-face %. Supervisor will review the counselor's schedule daily and schedule additional sessions to fill open spots in the counselor's schedule. Patients will be flagged by the Supervisor to attend or schedule counseling for the week.
Clinical Supervisor will be trained on how to utilize iAuditor for accountability/follow up/review Clinical supervisor will review signature reports via EHR and tableau, including various dashboards including treatment planning. Clinical Supervisor will provide a list of weekly and monthly treatment plans due to counselors to complete on a weekly basis.
Regional Director and Executive director to review monitoring reports during weekly regional calls Quality improvement to complete chart audits for training purposes and review expectations for each indicator per quarter.
Clinical staff meeting reviewed DDAP recommendations on 10/2/2024. Will address above education and training opportunities on the following dates: November 20, 2024 and November 27, 2024. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three of seven applicable records reviewed.
Client #1 was admitted on September 26, 2022 and was active at the time of review. A treatment plan dated March 27, 2024 indicated 2.5 hours of psychotherapy per month. In April and May 2024, the client only received 1.25 hours of psychotherapy.
Patient #2 was admitted to the outpatient level of care on April 18, 2024 and was active at the time of review. A treatment plan dated June 27, 2024 indicated 2.5 hours of psychotherapy a month. In July 2024, the client only received 1 hour of psychotherapy.
Patient #6 was admitted to the outpatient level of care on August 16, 2021 and was active at the time of review. A treatment plan dated April 26, 2024 indicated 1 hour of psychotherapy a month. In May 2024, the client only received .5 hours of psychotherapy. In July 2024, the client only received .75 hours of psychotherapy.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 1, 2023 licensing inspection.
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Plan of Correction
Education and Training efforts will be provided to Clinicians by Executive Director/Clinical Regional Clinical Supervisor/and Clinical Supervisor to address counseling requirements not being met per regulations. Education and training efforts will also focus on time management.
Action steps included providing the above training and education via Relias, individual supervision and direct observation as well as administration meetings and group clinical supervision. Administrative meetings to be held monthly and clinical supervision to be held on a weekly basis throughout the month of November to address the noted recommendations, areas of opportunity and improvements. Counselors will schedule a minimum of 5 hours of counseling each day and increase scheduling as needed to meet face-to-face daily service requirements. Counselors to utilize Methasoft scheduler to record all clinic activity and counseling sessions. At the conclusion of sessions, patients will be scheduled for the next session and flags placed within the EMR. Counselors will attempt to length session duration. Example ? If a patient usually stays for 30 minutes, attempt to have them stay an additional 15 minutes. Supervisor/Director will meet with counselor weekly to review scheduler, services due, documentation completions, and current face-to-face %. Supervisor will review the counselor's schedule daily and schedule additional sessions to fill open spots in the counselor's schedule. Patients will be flagged by the Supervisor to attend or schedule counseling for the week. Clinical Supervisor will be trained on how to utilize iAuditor for accountability/follow up/review Regional Director and Executive director to review monitoring reports during weekly regional calls Quality improvement to complete chart audits for training purposes and review expectations for each indicator per quarter. Clinical staff meeting reviewed DDAP recommendations on 10/2/2024. Will address above education and training opportunities on the following dates: November 6, 2024; November 13, 2024. |