INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 1, 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-IV, LLC dba Summit Treatment Services 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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715.23(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 a review of patient records, the facility failed to document an annual clinical evaluation of the patient ' s status in one of three patient records.Patient #5 was admitted on December 3, 2020 and discharged on January 27, 2023. There was no documentation of an annual clinical evaluation of the patient ' s status in patient record #5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed Patient Clinical Annual Evaluations in the 2/22/23 Staff/Clinical Meeting. In addressing this area, it was reviewed on proper scheduling of the Clinical Annuals in Methasoft and the need for timely completion.
Ongoing individual and group supervision will address proper and timely completion of annual clinical evaluations as part of ongoing clinical documentation requirements to meet DDAP standards and regulations. This individual and group supervision will be the responsibility of the Clinical Supervisor, Lead Counselor and Facility Director.
Action Steps and Plan to address the completion of Clinical Annual Evaluations are (1) Clinical Supervisor reviewed Patient Clinical Annual Evaluations in the 2/22/23 Staff/Clinical Meeting. (2) Clinical Supervisor, Lead Counselor and Facility Director will review Annual Clinical Evaluations a part of Individual and Group Supervision as needed, (3) Facility Director, Clinical Supervisor and Lead Counselor will monitor the timely and effective completion on Annual Clinical Evaluations in monthly chart audits through IAuditor and (4) Clinical Supervisor and Lead Counselor will address any ongoing issues with timely and effective completion of Annual Clinical Evaluations as needed |
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 a review of client records, the facility failed to document case consultations quarterly, as required by agency policy, in four of eight client records.Client #1 was admitted on April 20, 2022 and discharged on October 2, 2022. There were no case consults documented in client record #1.Client #2 was admitted on May 26, 2022 and discharged on October 25, 2022. There were no case consults documented in client record #2.Client #5 was admitted on December 3, 2020 and discharged on January 27, 2023. There were no case consults documented for 2022 in client record #5.Client #7 was admitted on August 10, 2021 and is currently active. There were no case consultations documented for 2022 in client record #7.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed Patient Case Consultations in the 2/22/23 Staff/Clinical Meeting. In addressing this area, it was reviewed on proper scheduling of the Case Consultations in Methasoft and the need for timely completion.
Ongoing individual and group supervision will address proper and timely completion of quarterly and annual Case Consultations as part of ongoing clinical documentation requirements to meet DDAP standards and regulations. This individual and group supervision will be the responsibility of the Clinical Supervisor, Lead Counselor and Facility Director.
Action Steps and Plan to address the completion of quarterly and annual Case Consultations are (1) Clinical Supervisor reviewed both quarterly and annual Case Consultations in the 2/22/23 Staff/Clinical Meeting. (2) Clinical Supervisor, Lead Counselor and Facility Director will review both quarterly and annual Case Consultations (depending if the patient is in their 1st year in treatment) a part of Individual and Group Supervision as needed, (3) Facility Director, Clinical Supervisor and Lead Counselor will monitor the timely and effective completion on Case Consultations in monthly chart audits through IAuditor and (4) Clinical Supervisor and Lead Counselor will address any ongoing issues with timely and effective completion of Case Consultations as needed. |