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 21, 2021 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record prior to the release of information. Client # 4 was admitted on June 1, 2021 and was still active at the time of the inspection. Authorizations to a funding source occurred on July 13, July 23, and August 10, 2021 without documentation of an informed and voluntary consent from the client for the disclosure of information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was held on 10-4-21 and 10-5-21 with all clinical staff related to releases. ED put into place a new system on 10-4-21 that the OM and ED review weekly any insurance changes to ensure that counselors are aware of immediately so that a release is obtained in live time. Clinical Supervisors and Managment team will ensure that this documeted in the chart for these pts. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on one of one applicable patient records review, the facility failed to provide documentation of the transferring narcotic treatment program transferring patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving facility.Patient # 5 was admitted on March 3, 2020 and was transferred on May 6, 2021. The transferring documentation was not provided in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED and clinical supervisors reviewed with clinical staff on 10-4-21 and 10-5-21 what must be done on all transfers and ensuring that all pages of a transfer are scanned into the charts. Clincal supervisors will review all transfers to ensure the proper papers are scanned into the chart. |
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 one of three applicable patient records reviewed, the facility failed to provide documentation of an annual evaluation of the patient's status being completed by the patient 's counselor and shall also be reviewed, dated and signed by the medical director.Patient # 5 was admitted on March 3, 2020 and was discharged on May 6, 2021. There was no annual evaluation in the patient record and was due no later than March 3, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10-5-21 all clinical staff were provided with a annual paperwork cheat sheet. The clinical supervisors will monitor during supervision that they are using this and that all the correct forms are being completed annually. ED will review the compliance with clinical supervisors in management meetings weekly. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow up is to occur within 7 days, 3 months, and 12 months of the patient discharge. A follow-up will occur within 1 week of discharge if the patient is referred to another agency. Client # 5 was admitted on March 3, 2020 and was discharged on May 6, 2021. There was no follow-up information documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clincal supervisor and ED on 10-4-21 and 10-5-21 reviewed how to look at services due report in Methasoft with all clincal staff. Clincal supervisors will monitor weekly for compliance with follow ups as well as all services due. Clinical supervisors will also review services due in supervision to ensure compliance. |