INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 6 & 7, 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 Centers PA-III, 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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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of the physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of May 28-June 3, 2023, the patient census was 576. The facility was required to provide at least 57.6 physician hours. There were only 35 physician hours documented. During the week of June 4-10, 2023, the patient census was 578. The physician was required to provide 57.8 physician hours. There were only 40.25 physician hours documented.During the week of June 11-17, 2023, the patient census was 581. The physician was required to provide 58.1 physician hours. There were only 27 physician hours documented. During the week of June 25-July 1, 2023, the patient census was 583. The physician was required to provide 58.3 physician hours. There were only 27 hours documented. During the week of July 2-8 2023, the patient census was 582. The physician was required to provide 58.2 physician hours. There were only 27 hours documented. During the week of July 9-15, 2023, the patient census was 583. The physician was required to provide 58.3 physician hours. There were only 27 hours documented. During the week of July 16-22, 2023, the patient census was 586. The physician was required to provide 58.6 physician hours. There were only 27 hours documented. During the week of July 23-29, 2023, the patient census was 591. The physician was required to provide 59.1 physician hours. There were only 27 hours documented. During the week of July 30- August 5, 2023, the patient census was 589. The physician was required to provide 58.9 physician hours. There were only 27 hours documented. During the week of August 6-12, 2023, the patient census was 587. The physician was required to provide 58.7 physician hours. There were only 27 hours documented. During the week of August 13-19, 2023, the patient census was 586. The physician was required to provide 58.6 physician hours. There were only 27 hours documented. During the week of August 20-26, 2023, the patient census was 586. The physician was required to provide 58.6 physician hours. There were only 27 hours documented. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Action Steps 1: PTC's physician recruiter will actively seek a NP/PA to fill the position. There are weekly calls every Tuesday at 11:00AM to discuss the open position and recruitment that include the recruiter, the RD and the ED.
Action Steps 2: The ED will monitor the census weekly beginning 9/11/23 and will utilize the the Regional Medical Director to supplement hours to ensure the regulation is being met.
Action Steps 3 : Effective immediately and ongoing weekly beginning 9/11/23, ED will contact Regional Medical Director in the absence of facility MD as needed.
Action Steps 4: The Regional Director will monitor the plan of correction is being followed and will discuss each Monday morning with the Executive Director. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time. During the week of May 28-June 3, 2023, the patient census was 576. The physician was required to provide one-third of the 57.6 hours, which equals to 19 hours. There were no physician hours documented. During the week of June 4-10, 2023, the patient census was 578. The physician was required to provide one-third of the 57.8 hours, which equals 19 hours. The physician only provided 12 hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action Steps 1: The ED will monitor the census weekly beginning 9/11/23 and will utilize the the Regional Medical Director to supplement hours to ensure the regulation is being met.
Action Steps 2 : Effective immediately and ongoing weekly beginning 9/11/23, ED will contact Regional Medical Director in the absence of facility MD as needed.
Action Steps 3: The Regional Director will monitor the plan of correction is being followed and will discuss each Monday morning with the Executive Director. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical by the narcotic treatment physician within the regulatory timeframe in one out of three applicable records reviewed.Patient #4 was admitted on September 2, 2022 and was still active at the time of the inspection. An annual physical was due no later than September 2, 2023; however, there is no documentation that one was completed at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Action Steps
1: Facility director met with medical staff on 9/11/23 to review requirements regarding annual physicals.
2: Facility Director reviewed the spreadsheet that is used to track all annual physicals to ensure that are completed within the timeframe of the requirement.
3. Facility Director will assist the nurses in monitoring the spreadsheet daily to ensure annual physicals are completed timely. |
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 the review of patient records, the facility failed to document an annual evaluation within the regulatory timeframe in three out three applicable records reviewed.Patient #2 was admitted on April 5, 2017 and was still active at the time of the inspection. The annual evaluation was due no later than April 5, 2023; however, there was no documentation that one was completed.Patient #4 was admitted on September 2, 2022 and was still active at the time of the inspection. An annual evaluation was due no later than September 2, 2023; however, there is no documentation that one was completed at the time of the inspection. Patient #6 was admitted on February 12, 2019 and was discharged on May 18, 2023. An annual evaluation was due no later than February 12, 2023; however, was not completed until March 7, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action Steps
1: Clinical supervisor met with counselors on 9/15/23 for individual supervision and reviewed the expectations regarding completing annual evaluations. 2: Clinical supervisor and Clinical director will meet with clinical staff on 10/2/23 to review documentation expectations regarding annual evaluation. 3: Clinical supervisor will review scheduled events due with counselors in monthly supervisions to ensure paperwork is completed timely. |
715.24(5)(ii) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(5) Minimum requirements for long-term detoxification treatment are as follows:
(ii) A narcotic treatment program shall perform an initial drug screening test or analysis. A narcotic treatment program shall perform at least one additional random test or analysis monthly on each patient during long-term narcotic detoxification.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment program performed at least one additional random test or analysis monthly on each patient during long-term narcotic detoxification in one out of eight records reviewed. Patient # 3 was admitted on June 16, 2023 and was still active at the time of the inspection. There was no documentation that a urinalysis was completed in August 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Action Steps 1:
Facility director met with medical staff on 9/11/23 to review requirements regarding monthly drug screens.
2: Facility Director reviewed the spreadsheet that is used to track all monthly drug screens to ensure that are completed within the timeframe of the requirement.
3. Facility Director will assist the nurses in monitoring the spreadsheet weekly in group supervision to ensure drug screens are completed monthly. |
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 out of six applicable records reviewed.Client #2 was admitted on April 5, 2017 and was still active at the time of the inspection. A treatment plan update was completed on March 28, 2023, and the next update was due no later than May 28, 2023; however, the next update was not completed until June 5, 2023. Client #4 was admitted on September 2, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 2, 2022, and the next update was due no later than February 2, 2023; however, it was not completed until February 6, 2023. Client #7 was admitted on July 7, 2022 and was discharged on June 23, 2023. A treatment plan update was completed on February 1, 2023, and the next update was due no later than April 1, 2023; however, it was not completed until April 3, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action Steps 1: Clinical Supervisor will meet with the three counselors in individual supervision scheduled during the month of October and will discuss the treatment plan update requirements and review the specific charting that was deficient. Clinical Supervisor will review specific treatment plan updates in individual supervisions with each counselor starting on 10/2/23.
Action Step 2: ED/Clinical Supervisor will meet with entire clinical staff on 10/2/23 to discuss the requirements of completing treatment plan updates.
Action Step 3: ED will monitor weekly that the treatment plan updates are being completed to meet the requirement by using a monthly spreadsheet and also tracking in the electronic health record. |