INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 8-10, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Centers PA-V, 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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715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
Based on an observation of a take home bottle label and discussions with the facility director and the nurse, the facility failed to label all take-home medication with all required information including the medication name, the dosage, or the date it was to be taken.
The findings include:
A take home bottle label was observed on December 9, 2014. The label was not packaged as required by Federal regulation which includes the dosage.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director contacted Tower, the software company used for Pinnacle Treatment Services of Aliquippa on 12/9/14 to have the dosage added to all take home bottles. As of 12/11/14 the dosage prints on all take home bottles. Dispensing nurses will check every take home bottle to ensure all required information is printed on the label prior to putting them into the lockbox. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of patient records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of eleven patient records.
The findings include:
Fifteen patient records were reviewed on December 8 - 10, 2014. Eleven of the fifteen patient records records were required to include the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in patient records #4, #6, #8, #11, and #12 did not include the type and frequency of treatment and rehabilitation services
Client #4 was admitted to treatment on July 8, 2014, and was discharged on August 27, 2014. The individual treatment and rehabilitation plan was developed on August 1, 2014 but did not include the type and frequency of treatment services.
Client #6 was admitted to treatment on September 22, 2014. The individual treatment and rehabilitation plan was developed on October 24, 2014, but did not include the type and frequency of treatment services.
Client #8 was admitted to treatment on July 30, 2014. The individual treatment and rehabilitation plan was developed on August 29, 2014, but did not include the type and frequency of treatment services.
Client #11 was admitted to treatment on August 11, 2014 . The individual treatment and rehabilitation plan was developed on September 11, 2014, but did not include the type and frequency of treatment services.
Client #12 was admitted to treatment on September 3, 2014. The individual treatment and rehabilitation plan was developed on October 3, 2014, but did not include the type and frequency of treatment services.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The agency will ensure compliance with 709.92(a)(2) through a retraining process. Facility Director will retrain all Clinical staff on completing treatment plans correctly, and review what information is required on every treatment plan. This training will take place by January 16, 2015. Clinical Supervisor, and Lead Counselor will review all treatment plans prior to signing to ensure all information is correct including the type and frequency of counseling. Peer Chart Review is also completed monthly to help ensure ongoing compliance. |