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 14-16, 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-I, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of employee # 3 having at least one year clinical experience prior to be hired in a counselor position. Employee # 3 was hired as a counselor on June 1, 2021 and was still in this position at the time of the inspection. Employee # 3's resume and job experience does not include at least one year of counseling experience with a Bachelor's degree.These findings were reviewed with facility staff during the licensing process.This ia a repeat citation from the Part 1 licensing inspection on August 6, 2020.
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Plan of Correction
The facility failed to document that each counselor met both the educational and experiential requirements for the position.
Employee #3 will be placed in the correct classification of Counselor Assistant until the amount of needed clinical experience is obtained to promote employee to Counselor.
Prior to employment all clinical staff will provide their received degree, requested transcripts, resume/application, and previous job descriptions (if needed). Also, a 3rd party company will conduct a comprehensive background check that includes degree verification. Based on this information all clinical staff will be placed in the appropriate employment classification (counselor / counselor assistant) based on the 704.7 regulations.
Human Resources will be informed of this violation to update hiring processes conducted prior to the employment of staff.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of at least one hour per week of direct observation during counselor assistant supervision. Employee # 9 was hired as a counselor assistant February 15, 2021 and was still in this position at the time of the inspection. A review of supervision notes provided did not indicate direct observation occurred. Employee # 10 was hired as a counselor assistant June 14, 2021 and was still in this position at the time of the inspection. A review of supervision notes provided did not indicate direct observation occurred. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that not all counselor assistants received one hour of direct observation from a trained counselor or clinical supervisor for the first 6-months of employment.
The Facility Director will be responsible for making sure that all counselor assistants are being supervised by a full-time clinical supervisor or clinician who meets the 704.6 or 704.7 qualifications.
Counselor Assistants will receive one hour of weekly direct observation during their first 6 months of employment and this period of weekly direct observation will be documented with the counselor assistants' required weekly supervision.
Company Compliance & Human Resources department will regularly review employee HR files to make sure all staffing regulations are being met.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A counseling session in a counselor office on the first floor near the nursing station could be seen and heard from the hallway. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to this regulation.
The facility will make sure all office doors and windows are closed when clinical services are being conducted to ensure patient confidentiality.
The facility will make sure all sound system/white noise machines are in working order and being utilized in facility hallways to provide external sound masking clinical sessions.
Facility Director is responsible for oversight of installation and implementation of these changes.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to provide hot water under pressure in the non-observational bathroom. The faucet was broken and inoperable.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that the facility failed to provide hot water under pressure in one restroom.
The facility will have the faucet in this restroom repaired and make sure the hot water is functioning under pressure.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill log, the facility failed to provide documentation of alternate exit routes used during fire drills. The fire drill log indicated "primary exits" and was not specific to the exit being used. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that the facility failed to prepare/document alternate exit routes to be used during fire drills.
The evacuation terminology used on the fire drill logs was 'primary exits' and 'secondary exits' which is how the facility evacuation plans are labeled.
Moving forward, the facility will be more specific when documenting utilized exits on the fire drill logs.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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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 to include the purpose of the disclosure. Client # 5 was admitted on June 9, 2020 and was discharged on July 28, 2021. An informed and voluntary consent from the client for the disclosure of information to a "government agency" signed and dated on June 4, 2021 did not provide the purpose of the release.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to appropriately document one informed and voluntary consent in one record that was reviewed.
The facility will ensure that all clinical staff appropriately complete all aspects of the informed and voluntary consent for patients.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to informed and voluntary consent.
The facility did change electronic documentation system in 2020. Facility will research if new system has the ability to make sure all aspects of a form has to be completed before allowing the form to be signed and completed. If this is possible, information will be provided to cooperate for possible implementation.
Supervisory & Compliance staff will continue to conducted chart reviews which does include this aspect of the patient file.
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709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on five 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 to include a dated signature of the client.Client # 1 was admitted on September 22, 2014 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated September 13, 2021 to a funding agency, government agency, emergency contact, and PCP did not have a valid signature by the client but instead had telehealth verbal consent in the signature line.Client # 2 was admitted on June 8, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 8, 2021 to a medical association, other treatment provider, and PCP did not have a valid signature by the client but instead had telehealth verbal consent in the signature line.Client # 3 was admitted on June 18, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 18, 2021 to a medical association did not have a valid signature by the client but instead had telehealth verbal consent in the signature line.Client # 5 was admitted on June 9, 2020 and was discharged on July 28, 2021. An informed and voluntary consent from the client for the disclosure of information dated May 26, 2021 to a hospital did not have a valid signature by the client but instead had telehealth verbal consent in the signature line.Client # 6 was admitted on June 18, 2014 and was discharged on June 1, 2021. An informed and voluntary consent from the client for the disclosure of information dated May 27, 2021 to another treatment facility did not have a valid signature by the client but instead had telehealth verbal consent in the signature line.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to appropriately document informed and voluntary consent including in multiple record that was reviewed, which included incomplete signatures.
The COVID-19 pandemic caused a lot of issues around this regulation. Was difficult with some patients receiving extended exception bottles, doing sessions via telehealth, being quarantined and many other factor brought on by the pandemic.
The facility will ensure that all clinical staff appropriately complete all aspects of the informed and voluntary consent for patients, which includes dated signatures.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to informed and voluntary consent.
The facility did change electronic documentation system in 2020. Facility will research if new system has the ability to make sure all aspects of a form has to be completed before allowing the form to be signed and completed. If this is possible, information will be provided to cooperate for possible implementation.
Supervisory & Compliance staff will continue to conducted chart reviews which does include this aspect of the patient file.
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709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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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 to include date, event or condition upon which the consent will expire. Client # 5 was admitted on June 9, 2020 and was discharged on July 28, 2021. An informed and voluntary consent from the client for the disclosure of information dated June 4, 2021 to government agency did not provide the date, event or condition upon which the consent will expire. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to appropriately document one informed and voluntary consent in one record that was reviewed.
The facility will ensure that all clinical staff appropriately complete all aspects of the informed and voluntary consent for patients.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to informed and voluntary consent.
The facility did change electronic documentation system in 2020. Facility will research if new system has the ability to make sure all aspects of a form has to be completed before allowing the form to be signed and completed. If this is possible, information will be provided to cooperate for possible implementation.
Supervisory & Compliance staff will continue to conducted chart reviews which does include this aspect of the patient file.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained 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 to include documentation of a copy of the client consent being offered to the client.Client # 5 was admitted on June 9, 2020 and was discharged on July 28, 2021. An informed and voluntary consent from the client for the disclosure of information dated June 4, 2021 to government agency, a hospital dated May 26, 2021, or another treatment facility dated July 9, 2021 did not document a copy of the client consent being offered to the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to appropriately document if copy of completed consent was offered to patient.
The facility will ensure that all clinical staff appropriately complete all aspects of the informed and voluntary consent for patients, which will offering copy to patient and appropriately documenting patient response.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to informed and voluntary consent, which will offering copy to patient and appropriately documenting patient response.
The facility did change electronic documentation system in 2020. Facility will research if new system has the ability to make sure all aspects of a form has to be completed before allowing the form to be signed and completed. If this is possible, information will be provided to cooperate for possible implementation.
Supervisory & Compliance staff will continue to conducted chart reviews which does include this aspect of the patient file.
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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 two of three applicable patient records reviewed, the facility failed to provide documentation of a narcotic treatment program providing each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years.Patient # 2 was admitted on June 8, 2021 and was still active at the time of the inspection. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month. For the month of June 8-July 8 the patient had 0 hours of psychotherapy, July 8-August 8 the patient had 1 hour, August 8-September 8 the patient had 1 hour.Patient # 3 was admitted on June 18, 2021 and was still active at the time of the inspection. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month. For the month of June 18-July 18 the patient had 35 minutes of psychotherapy.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 23, 2021 and October 25, 2019 licensing inspection.
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Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for all patient records that were reviewed.
The COVID-19 pandemic caused a lot of issues around this regulation.
The facility will ensure that all patients receive the required of monthly psychotherapy. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Clinical staff will maintain accurate records of when patients cancel, no-show, or reschedule appointments. Also, if patients continually remain out of compliance with treatment requirements treatment contracts will be utilized. Clinical staff will utilize Electronic Record reports to periodically check counseling compliance for their caseloads.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to when other staff are out of the building.
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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 one of four applicable patient records reviewed, the facility failed to provide documentation of a narcotic treatment program providing each patient an average of 1 hour of psychotherapy per month for the patients third and fourth year of treatment.Patient # 4 was admitted on August 29, 2018 and was still active at the time of the inspection. A review of progress notes indicates the patient did not receive 1 hour of psychotherapy per month. For the months of June, July, and August the patient did not receive any psychotherapy.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide 1 hours of psychotherapy services for all patient records that were reviewed.
The COVID-19 pandemic caused a lot of issues around this regulation.
The facility will ensure that all patients receive the required of monthly psychotherapy. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Clinical staff will maintain accurate records of when patients cancel, no-show, or reschedule appointments. Also, if patients continually remain out of compliance with treatment requirements treatment contracts will be utilized. Clinical staff will utilize Electronic Record reports to periodically check counseling compliance for their caseloads.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to when other staff are out of the building.
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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 # 6 was admitted on July 18, 2014 and was transferred on June 1, 2021. The transferring documentation was not provided in the client record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 23, 2021 licensing inspection.
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Plan of Correction
Facility will ensure that all patients required documentation is provided to transferring narcotic treatment program when appropriate and with signed ROIs. The transferred documentation will also be imported into the electronic medical record.
When the facility has prior knowledge of potential patient transfers patient releases/consents will be completed in preparation to send required transfer documents to transferring facility upon request or prior.
If prior release/consents have not been completed prior to transfer notice then the facility will only transfer documents covered under the release/consent provided by the transferring facility.
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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 four 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 June 9, 2020 and was discharged on July 28, 2021. There was no Annual evaluation in the patient record and was due no later than June 9, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to complete all the required documentation needed for a patient's annual evaluation in one reviewed chart.
Facility moved to a new electronic documentation system towards the end of 2020 which has made it more difficult to tract completed patient documentation, especially when staff leave and patient are assigned to new counselors. This issue will continue to be reported to corporate for possible resolution in the new electronic documentation system.
The facility will ensure that all required annual documentation is completed as required by regulations and clinical staff will keep a secondary tracking system to monitor compliance.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to required clinical annual documentation.
Open counseling positions will be filled to help ease the burden on current counseling staff and to make sure patient required documentation does not get missed.
Supervisory & Compliance staff will continue to conducted chart reviews which does include this aspect of the patient file.
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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 three of three applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in accordance to the facility policy and procedure manual. The facility policy and procedure manual indicates 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 June 9, 2020 and was discharged on July 28, 2021. The first follow-up occurred on September 2, 2021 but was due no later than August 6, 2021.Client # 6 was admitted on July 18, 2014 and was discharged on June 1, 2021. There was no follow-up information documented in the patient record.Client # 7 was admitted on December 11, 2013 and was discharged on May 2, 2021. The first follow-up occurred on July 8, 2021 but was due no later than May 11, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to complete required patient follow-ups post discharge per facility policies and procedure manual.
Facility moved to a new electronic documentation system towards the end of 2020 which has made it more difficult to tract completed patient documentation, especially when staff leave and patient are assigned to new counselors. This has also effected the scheduling & completion of discharge follow-ups. This issue will continue to be reported to corporate for possible resolution in the new electronic documentation system.
The facility will ensure that all required discharge follow-ups are completed per facility policies/procedure manual.
Supervisory Staff will meet with program staff in treatment team meeting and review all requirements related to scheduling & completion of discharge follow-ups.
Supervisory & Compliance staff will continue to conducted chart reviews which does include this aspect of the patient file.
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