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 26 & 27, 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-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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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 a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in two out of four applicable records reviewed.
Patient # 3 was admitted on October 12, 2022 and was still active at the time of the inspection. In June, the patient received only one hour of individual psychotherapy.
Patient #4 was admitted on November 22, 2022 and was still active at the time of the inspection. In July, the patient received only one hour of individual psychotherapy.
This is a repeat citation from the September 16, 2021 and September 27, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for two of the reviewed charts.
Supervisory Staff will review requirements for counseling hours of patients in their first 2 years in clinical group supervision and staff meeting throughout the month of November. While addressing this area, it will be reviewed that all patients in their first 2 years in treatment are required to meet 2.5 hours of individual and group counseling per month. Ongoing individual and group supervision will address progress in and completion of counseling hours to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of individual and group counseling totaling 2.5 hours/month are (1) Supervisory Staff will review counseling requirements in clinical group supervision and staff meeting throughout the month of November. (2) Monthly individual supervision will address counseling requirements are met and barriers to meeting these requirements. (3) Individual patient charts will be reviewed during specific individual supervision sessions and counseling requirements will be discussed. (4) Education and training on time management and ensuring counseling requirements are met will be part of group supervision and staff meetings. (5) Counseling requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient that had been in treatment four years or longer with at least 1 hour of group or individual psychotherapy every 2 months in two out of four applicable records.
Patient #6 was admitted on April 14, 2008 and was still active at the time of the inspection. There was no documentation in the patient record that the patient received any psychotherapy in May, June or July 2023.
Patient #7 was admitted on February 7, 2019 and discharged on December 30, 2022. There was no documentation in the patient record that the patient received any psychotherapy in September or November 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide 1 hour of psychotherapy services every 2 months for two of the reviewed charts.
Supervisory Staff will review requirements for counseling hours of patients after their first 4 years in clinical group supervision and staff meeting throughout the month of November. While addressing this area, it will be reviewed that all patients after their first 4 years in treatment are required to meet 1 hour of individual or group counseling every 2 months. Ongoing individual and group supervision will address progress in and completion of counseling hours to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of individual and group counseling totaling 1 hour every 2 months are (1) Supervisory Staff will review counseling requirements in clinical group supervision and staff meeting throughout the month of November. (2) Monthly individual supervision will address counseling requirements are met and barriers to meeting these requirements. (3) Individual patient charts will be reviewed during specific individual supervision sessions and counseling requirements will be discussed. (4) Education and training on time management and ensuring counseling requirements are met will be part of group supervision and staff meetings. (5) Counseling requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team.
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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 the review of patient records, the facility failed to document an annual evaluation with all areas of regulation addressed within the regulatory timeframe in two out four applicable records reviewed.
Patient #5 was admitted on May 15, 2019 and was still active at the time of the inspection. The annual evaluation was due no later than May 15, 2023; however, was not completed until May 19, 2023.
Patient #6 was admitted on April 14, 2008 and was still active at the time of the inspection. The annual evaluation was due no later than April 14, 2023; however, was not completed until August 29, 2023.
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 two reviewed charts.
Supervisory Staff will review requirements for annual evaluations being completed in clinical group supervision and staff meeting throughout the month of November. While addressing this area, it will be reviewed that all patients must have annual evaluations completed annually, no more than 365 days from the previous annual evaluation completion date.
Ongoing individual and group supervision will address progress in and completion of annual evaluations to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of annual evaluations are (1) Supervisory Staff will review regulations around timely completion of annual evaluations in clinical group supervision and staff meeting throughout the month of November. (2) Monthly individual supervision will address completion of annual evaluations and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and counseling requirements will be discussed. (4) Education and training on timely completion of annual evaluations will be part of group supervision and staff meetings. (5) Counseling requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures that a comprehensive treatment plan must be completed within 30 days of admission in three out of four applicable records reviewed.
Client #1 was admitted on November 3, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 3, 2022; however, was not completed until December 12, 2022.
Client #3 was admitted on October 12, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 12, 2022; however, was not completed until December 15, 2022.
Client #4 was admitted on November 22, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 22, 2022; however, was not completed until January 10, 2023.
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 for individual treatment and rehabilitation plan in three reviewed charts.
Supervisory Staff will review requirements for completion of comprehensive treatment plans throughout the months of November and December. While addressing this area, it will be reviewed that all patients must have comprehensive treatment plans completed within 30 days of treatment admission. Ongoing individual and group supervision will address progress in and completion of comprehensive treatment plans to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of comprehensive treatment plans when required by regulation are (1) Supervisory Staff will review regulations around comprehensive treatment plans in clinical group supervision and staff meeting throughout the months of November and December. (2) Monthly individual supervision will address completion of comprehensive treatment plans and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and completion of comprehensive treatment plans will be part of that review. (4) Education and training on timely completion of comprehensive treatment plans will be part of group supervision and staff meetings. (5) Review of comprehensive treatment plans will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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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 six out of seven applicable records reviewed.
Client #1 was admitted on November 3, 2022 and was still active at the time of the inspection. A treatment plan was completed on December 12, 2022, and the next update was due no later than February 12, 2023; however, it was not completed until February 20, 2023. A treatment plan update was completed on April 11, 2023, and the next update was due no later than June 11, 2023; however, it was not completed until June 23, 2023.
Client #2 was admitted on June 13, 2023 and was still active at the time of the inspection. A treatment plan was completed on July 12, 2023, and the next update was due no later than September 12, 2023; however, it was not completed until September 21, 2023.
Client #4 was admitted on November 22, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 17, 2023, and the next update was due no later than April 17, 2023; however, it was not completed until May 5, 2023.
Client #5 was admitted on May 15, 2019 and was still active at the time of the inspection. A treatment plan update was completed on December 15, 2022, and the next update was due no later than February 15, 2023; however, it was not completed until April 6, 2023. A treatment plan update was completed on May 9, 2023, and the next update was due no later than July 9, 2023; however, it was not completed until September 13, 2023.
Client #6 was admitted on April 14, 2008 and was still active at the time of the inspection. A treatment plan update was completed on November 17, 2022, and the next update was due no later than January 17, 2023; however, was not completed until April 4, 2023. The next update was due no later than June 4, 2023; however, was not completed until August 1, 2023.
Client #7 was admitted on February 7, 2019 and was discharged on December 30, 2022. A treatment plan update was completed on September 6, 2022, and the next update was due no later than November 6, 2022; however, there is no documentation that one was completed.
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 for individual treatment and rehabilitation plan updates in six reviewed charts.
Supervisory Staff will review requirements for completion of comprehensive treatment plans throughout the months of November and December. While addressing this area, it will be reviewed that all patients must have completed treatment plans completed within 60 days of the previous update or from the comprehensive treatment plan. Ongoing individual and group supervision will address progress in and completion of treatment plan updates to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of treatment plan updates when required by regulation are (1) Supervisory Staff will review regulations around comprehensive treatment plan updates in clinical group supervision and staff meeting throughout the months of November and December. (2) Monthly individual supervision will address completion of treatment plan updates and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and completion of treatment plan updates will be part of that review. (4) Education and training on timely completion of treatment plan updates will be part of group supervision and staff meetings. (5) Review of comprehensive treatment plans updates will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of seven applicable records reviewed.
Client #3 was admitted on October 12, 2022 and was still active at the time of the inspection. The treatment plan dated March 10, 2023, indicated 2.5 hours of psychotherapy a month. In June 2023, the client only received one hour of psychotherapy.
Client #4 was admitted on November 22, 2022 and was still active at the time of the inspection. The treatment plan dated February 17, 2023, indicated 2.5 hours of psychotherapy a month. In July 2023, the client only received one hour of psychotherapy.
Client #6 was admitted on April 14, 2008 and was still active at the time of the inspection. A treatment plan dated April 4, 2023, indicted one hour a month of psychotherapy. There was no documentation that the client received psychotherapy in the May, June or July 2023.
Client #7 was admitted on February 7, 2019 and was discharged on December 30, 2022. A treatment plan dated September 6, 2022, indicted psychotherapy two times a month. There was no documentation that the client received any psychotherapy in the months of September, October and November 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to assure that all clinical services are provided in accordance with the patient's individual treatment and rehabilitation plan in four reviewed charts.
Supervisory Staff will review requirements needed to make sure clinical services are being provided in accordance with individualized plans when reviewing regulations around individual treatment plan throughout the months of November and December. While addressing this area, it will be reviewed that all patient individualized treatment plans must specify the type/frequency of clinical services being provided and the importance that the patient follow through with treatment plan clinical service requirements (type/frequency of clinical services will be documented in the body of the treatment plan for additional clarification). Ongoing individual and group supervision will address progress in and completion of treatment plan updates to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the adherence of clinical services per individual treatment plans are (1) Supervisory Staff will review regulations around clinical services and comprehensive treatment plan compliance in clinical group supervision and staff meeting throughout the months of November and December. (2) clinical staff will document type/frequency of clinical services within the body of the treatment plan for additional clarification on services to be received (3) Monthly individual supervision will address clinical services/treatment plan compliance and barriers to meeting this regulation. (4) Individual patient charts will be reviewed during specific individual supervision sessions and clinical services/treatment plan compliance will be part of that review. (5) Education and training on clinical services and treatment plan compliance will be part of group supervision and staff meetings. (6) Review of compliance related to clinical services and treatment plan compliance will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the identified timeframe listed in the facility ' s policy and procedure manual in three out of nine applicable client records. The facility's policy and procedures manual states that case consultations are completed at three months, six months, nine months, and then yearly.
Client #2 was admitted on June 13, 2023 and was still active at the time of the inspection. A case consultation was due no later than September 13, 2023; however, there was no documentation that one was completed.
Client #3 was admitted on October 12, 2022 and was still active at the time of the inspection. A case consultation occurred on January 6, 2023, and the next one was due no later than April 6, 2023; however, was not completed until June 8, 2023.
Client #6 was admitted on April 14, 2008 and was still active at the time of the inspection. A case consultation was due no later than April 14, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to appropriately document case consultations in three record that was reviewed.
Supervisory Staff will review requirements for case consultations being completed in clinical group supervision and staff meeting throughout the month of November. While addressing this area, it will be reviewed that all patients must have case consultations done by the 3-month, 6-month, 9-month and 12-month mark in the first year and annually after the first year. Ongoing individual and group supervision will address progress in and completion of case consults to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of case consults are (1) Supervisory Staff will review regulations around case consultations in clinical group supervision and staff meeting throughout the month of November. (2) Monthly individual supervision will address completion of case consultations and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and completion of case consultations will be part of that review. (4) Education and training on timely completion of case consults will be part of group supervision and staff meetings. (5) Case consultation requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team.
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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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three discharged records reviewed.
Client #9 was admitted on December 24, 2001 and discharged on November 2, 2022. A follow up was due per the facility ' s policy and procedure manual at 60 days and 90 days after discharge; however, there is no documentation that one occurred.
This is a repeat citation from the September 16, 2021 and September 27, 2022 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to appropriately document discharge follow-ups in one record that was reviewed.
Supervisory Staff will review requirements for patient follow-ups in clinical group supervision and staff meeting throughout the month of November. While addressing this area, facility policies/procedure around discharge follow-ups will be reviewed.
Ongoing individual and group supervision will address progress in and completion of case consults to meet DDAP standards and regulations.
Action steps and plan to address the completion of discharge follow-ups are (1) Current EMR has an issue tracking follow-up linked to discharges of clinical staff no longer employed with the company, so an external tracking system is implemented outside the current EMR to report and monitor completion of patient discharge follow-ups. Supervisory Staff will ensure that all clinical staff are appropriately trained on required discharge follow-up documentation. (2) Supervisory Staff will review regulations around discharge follow-ups in clinical group supervision and staff meeting throughout the month of November. (3) Education and training on timely completion of discharge follow-ups will be part of group supervision and staff meetings. (4) Discharge follow-up requirements will be reviewed and monitored with random chart audits completed by supervisory staff and compliance team.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting follow-up information for the outpatient records was submitted and approved by the Department for the September 16, 2021, and September 27, 2022, annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the September 26 & 27, 2023 licensing inspection.
A plan of correction for completing and documenting annual evaluations was submitted and approved by the Department for the September 16, 2021, and September 27, 2022, annual licensing inspections. Completing and documenting annual evaluations was again found to be a deficiency in the September 26 & 27, 2023 licensing inspection.
A plan of correction for providing 2.5 hours of psychotherapy during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in the narcotic treatment program records was submitted and approved by the Department for the September 16, 2021, and September 27, 2022, annual licensing inspections. Providing 2.5 hours of psychotherapy during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, was again found to be a deficiency in the September 26 & 27, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure the plans of correction are implemented by the corrective action date and clinical supervisor will assist in the monitoring process. Clinical supervisor will monitor progress of the plans and quarterly reviews of plans of correction implantation will occur during staff/supervision meetings. Additional monitoring will occur monthly through chart audits completed by the PTC compliance team and if deficiencies are noted they will be reviewed within the month. If the plan of corrections appear to be not working as written, a supervisory meeting will occur to adjust the current plans. The facility director will report to the project director the findings each quarter during PTCs regional operations meeting.
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