INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection conducted on February 17, 2021, 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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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 the review of client records, the facility failed to verify the age of the client in one of six client records.
Client # 5 was admitted on April 29, 2020 and discharged on June 3, 2020. There was no verification of the client's age documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Medical Assistant/Receptionist will collect Photo ID when Patient arrives to PTSA. Medical Assistant/Receptionist will scan and upload to chart after validating patient is over 18 years old. Clinical Supervisor and/or Director will review chart after admissions procedures are complete before patient receives first dose of medication to ensure compliance. |
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 the review of client records, the facility failed to verify the client's identity in one of six client records.
Client # 5 was admitted on April 29, 2020 and discharged on June 3, 2020. There was no verification of the client's identity documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Medical Assistant/Receptionist will collect Photo ID when Patient arrives to PTSA. Medical Assistant/Receptionist will scan and upload to chart after validating patient is over 18 years old and validating this is the person present for appointment. Clinical Supervisor and/or Director will review chart after admissions procedures are complete before patient receives first dose of medication to ensure compliance. |
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 the review of client records, the facility failed to review and update the treatment and rehabilitation plans at least every 60 days in two of four client records.
Client # 3 had an update due to be completed by January 25, 2021. There was no documentation that the update had been completed.
Client # 7 had an update due to be completed by July 5, 2020. There was no documentation that the update had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will work with Supervisor on a tracking system to ensure no treatment plans are missed/deficient. Director will work with staff on weekly submission of services due to ensure timeliness of all treatment plans. Director will work EHR to create a fail safe of removing the prompt for due dates. Clinical supervisor will audit charts and submit corrections to staff and Director weekly to ensure all treatment plans are complete timely. |