INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on February 18-20, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pinnacle Treatment Centers PA-V, LLC was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document a written fire drill log that includes the exit route used.
The fire drill logs from February 2019 to January 2020 were reviewed on February 18-20, 2020. The exit route noted on the logs stated, "designated exit". The exit route used was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC: Executive Director will review PTSA policy with Administrative staff in charge of completely fire drill. Executive Director will oversee the completion of drills and appropriate documentation of fire drills with noted exits of how drill was completed. Director will review health and safety book monthly and conduct safety meetings with staff to ensure proper follow through. QI will audit quarterly for compliance. This change was made immediate 3/4/20 upon receipt of citation. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file a written unusual incident report involving the presence of an ambulance, within 3 business days.
Unusual incident reports were reviewed on February 18-20, 2020. An ambulance was present at the facility on three separate occasions. The unusual incident reports were not sent within 3 business days of the event.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC: Executive Director will write, review and submit to DDAP within 72 hours when an unusual incident report in completed. Changes for this was effective 3/4/20 at the time of citation review and Executive Director will be responsible for ensuring ongoing compliance. QI will audit quarterly to add additional review of submission to timeline. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility failed to ensure the narcotic treatment physician reviewed the dosage levels at least twice a year in four of four patient records.
Ten patient records were reviewed on February 18-20, 2020. Eight records were reviewed as methadone patients, and four records required dose reviews.
Patient # 1 documented a semiannual dose review on November 26, 2019 that was completed by the physcian's assistant.
Patient # 4 was missing semiannual dose reviews for 2019.
Patient # 5 was missing semiannual dose reviews for 2019.
Patient # 6 documented a semiannual dose review on October 26, 2019 that was completed by the physician's assistant.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
POC: Policy was reviewed with Medical Director, additional Physicians as well as Physician Assistant. All were notified of Physician being responsible to review dose levels at the review of citation provided 3/4/20. All members of the treatment team are in agreement of regulation and responsibility being under the direction of the Physician. Executive Director will audit monthly for compliance as well as a member of the QI team. Executive Director will remain responsible to monitoring of this regulation to ensure compliance is being met. Changes are in effect immediately upon receipt of citation. |
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
The facility failed to document what materials were sent to the receiving narcotic treatment program in one of one patient record.
Ten patient records were reviewed on February 18-20, 2020. Eight were reviewed as methadone patients. One required documentation of transfer material.
Patient # 7 was transferred on December 17, 2019. There was no documentation that the receiving program was sent transferring information.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
PTSA policy was reviewed with Clinical supervisor, medical team and clinical team. Discharge tracking sheet was completed and provided as reference to all clinical and medical staff to ensure proper notification of transfer to the outgoing clinic to ensure that transfer paperwork from PTSA narcotic treatment program is sent to the transfer clinic. Clinical supervisor will review all Discharges within 24 hours of completion and Executive director will monitor for compliance and completion. Intake packets were completed at the finish of audit and put into place effectively immediately 3/4/20. Executive Director will remain responsible to completion and adherence to this regulation |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document that the facility notified, in writing, the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in two of two patient records.
Ten patient records were reviewed on February 18-20, 2020. Eight were reviewed as methadone patients. Two were reviewed as transfer ins and required written notification of transfer.
Patient records # 1 and 2 were missing documentation of the written transfer notice.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC: PTSA policy was reviewed with Clinical supervisor, medical team and clinical team. Intake tracking sheet was completed and provided as reference to all clinical and medical staff to ensure proper notification of transfer and receiving transfer paperwork from previous narcotic treatment program. This includes the date of admission, first dose provided, and transfer documentation. Clinical supervisor will review all intakes within 24 hours of completion and Executive director will monitor for compliance and completion. Intake packets were completed at the finish of audit and put into place effectively immediately 3/4/20. Executive Director will remain responsible to completion and adherence to this regulation |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
The facility failed to file a written Unusual Incident Report with the Department within 48 hours following the death of a patient.
The unusual incident reports were reviewed on February 18-20, 2020. An unusual incident report involving a death was completed on June 8, 2019. The report was submitted to DDAP on June 12, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
POC: Executive Director will write, review and submit to DDAP within 48 hours when an unusual incident report in completed. Changes for this will be effective 3/4/20 and Executive Director will be responsible for ensuring ongoing compliance. QI will audit quarterly to add additional review of submission to timeline. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
The facility failed to document discharge summaries in three of three client records.
Client records were reviewed on February 18-20, 2020. Three were reviewed as discharged clients and required a discharge summary.
Client records # 6, 7 and 8 were discharged clients. All three were missing discharge summaries.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
POC: Executive Director and Project Director reviewed setting in SMART EMR and it was noted an error in settings in prompting discharge summaries. Error has been corrected when notification of citation was provided 3/4/20. Executive Director will discharge a patient and go directly into chart to ensure prompting of the service in completed at time of discharge. Clinical Supervisor will monitor compliance of completion of the service by clinical team. Executive Director will be responsible for adherence to regulation and policy. QI will audit quarterly for additional layer of compliance. |