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 28, 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-II, 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 six applicable records reviewed.
Patient #2 was admitted on May 23, 2023 and was still active at the time of the inspection. Patient #2 only received one hour and fifteen minutes of group psychotherapy for the month of July 2023 and no individual psychotherapy hours.
Patient #8 was admitted on May 31, 2022 and discharged on March 24, 2023. Patient #8 only received one hour and fifteen minutes of individual psychotherapy and no group psychotherapy in January 2023.
This is a repeat citation from the September 16, 2021 and September 28, 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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715.23(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 March 26, 2012 and was still active at the time of the inspection. An annual evaluation was completed on March 23, 2022, and the next was due no later than March 23, 2023; however, it was not completed until March 29, 2023.
Patient #10 was admitted on June 2, 2022 and was still active at the time of the inspection. An annual evaluation was due no later than June 2, 2023; however, it was not completed until June 5, 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(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 ten applicable records reviewed.
Client #1 was admitted on March 22, 2023 and was still active at the time of the inspection. A treatment plan was completed on June 13, 2023, and the next update was due no later than August 13, 2023; however, it was not completed until August 15, 2023.
Client #2 was admitted on May 23, 2023 and was still active at the time of the inspection. A treatment plan was completed on June 14, 2023, and the next update was due no later than August 14, 2023; however, it was not completed until August 17, 2023.
Client #3 was admitted on June 2, 2023 and was still active at the time of the inspection. A treatment plan was completed on June 27, 2023, and the next update was due no later than August 27, 2023; however, it was not completed until August 29, 2023.
Client #4 was admitted on January 31, 2023 and was still active at the time of the inspection. A treatment plan update was completed on February 20, 2023, and the next update was due no later than April 20, 2023; however, it was not completed until May 2, 2023.
Client #7 was admitted on July 11, 2019 and discharged on July 13, 2023. A treatment plan update was completed on December 27, 2022, and the next update was due no later than February 27, 2023; however, it was not completed until March 8, 2023.
Client #8 was admitted on May 31, 2022 and was discharged on March 24, 2023. A treatment plan update was completed on October 26, 2022, and the next update was due no later than December 26, 2022; however, it was not completed until December 29, 2022.
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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709.17(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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
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 28, 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 28, 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 is implemented by the corrective action date and clinical supervisor will assist in the monitoring process. Clinical supervisor will monitor progress of the plan 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 correction appears to be not working as written, a supervisory meeting will occur to adjust the current plan. The facility director will report to the project director the findings each quarter during PTCs regional operations meeting.
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