INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection on November 2, 2023 through November 3, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Family Health Care LLC, dba Lansdowne 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in three applicable records reviewed. The policy and procedure manual stated that clients may be placed on inactive status after three missed doses, and may remain on inactive status for up to 30 days. Client records remained open beyond 30 days of program inactivity in three of three records reviewed.
Client # 4 was admitted on July 1, 2022 and was discharged on November 1, 2023. The most recent client attendance at the facility was May 26, 2023.
Client # 10 was admitted on June 1, 2023 and was discharged on September 15, 2023. The most recent client attendance at the facility was June 22, 2023.
Client # 13 was admitted on January 28, 2023 and was discharged on September 6, 2023. The most recent client attendance at the facility was July 22, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be retrained on discharge policies and expectations on 12/7/2023 by the ED and clinical leads. ED and clinical leads will review the list of patients who are due to be discharged each week and follow up with staff to ensure that discharges are made according to the timeframes in Pinnacle's policies. |
709.28 (c) 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.
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Observations
Based on a review of thirteen client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in one record reviewed.
Client # 2 was admitted on October 31, 2023 and was active at the time of the inspection. The record contained documentation of a disclosure of client identifying information to a previous treatment provider on October 31, 2023; however, the record did not contain an informed and voluntary consent form to the provider.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Nursing and medical staff will be retrained by the ED on checking the chart for valid releases before contacting any provider agency for information on 12/8/2023. All clinical staff will be retrained by the ED on releases required at admission for anyone transferring from another provider on 12/7/2023.
All staff to be retrained on documents required to be signed by the patient prior to contacting any outside entity by the ED. Nursing and medical staff to be trained on 12/8/2023 and clinical staff to be trained on 12/7/2023. The ED and clinical leads will monitor compliance through completion of intake audits as well as monthly chart audits completed by site and QI staff. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of thirteen client records, the facility failed to ensure that consent to release information forms included the name of the person, agency, or organization to whom the disclosure is made in one record reviewed.
Client # 5 was admitted on October 6, 2023 and was active at the time of the inspection. The record contained a consent to release information form to an emergency contact signed by the client on October 12, 2023 that was missing the name of the person, agency, or organization.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The release of information was expired immediately following the site visit. Since the patient was discharged, a new release will be obtained if they were to readmit.
Clinical leads and ED will complete intake audits and monthly chart audits for each counselor to ensure compliance in completing releases correctly. Training on the proper completion of releases will be delivered by the ED and/or clinical leads on a quarterly basis to ensure continued compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that medication orders were complete according to the facility's policy and procedures in one of ten records reviewed. According to the project's policy on medication orders, complete medication orders contain the signature of the physician.
Patient # 5 was admitted on October 6, 2023 and was active at the time of the inspection. A medication order was entered on October 13, 2023, and was not signed by the prescriber until October 19, 2023.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff will receive retrained on 12/5/2023 by the ED on signature expectations. ED will run signature reports Mondays, Wednesdays, and Fridays to ensure that signatures are being completed in a timely fashion. |
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 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 in three of five applicable records.
Patient # 1 was admitted on October 29, 2021 and was active at the time of the inspection. The patient was required to have at least 2.5 hours of psychotherapy per month. The patient did not receive any psychotherapy hours for the month of October 2023.
Patient # 7 was admitted on September 22, 2023 and was active at the time of the inspection. The patient was required to have at least one hour of individual psychotherapy per month. The patient did not receive any individual therapy during the month of October 2023.
Patient # 8 was admitted on September 18, 2023 and was active at the time of the inspection. The patient was required to have at least 2.5 hours of psychotherapy per month. The patient only received one hour of psychotherapy for the month of October 2023.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff to be retrained on the clinical service expectations for patients based on years in service as well as documenting patient refusals when they occur on 12/7/2023 by the ED and clinical leads. ED and Talent Team will continue to heavily recruit for all vacant positions to ensure that there is staff available to deliver clinical services. All vacant positions are expected to be filled by 1/1/2024. |
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 a review of patient records, the transferring facility failed to document what materials were sent to the receiving facility in one of one applicable record reviewed.
Patient # 3 was admitted on May 4, 2020 and transferred to another narcotic treatment program on September 20, 2023. There was no documentation related to what materials were sent to the receiving facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff to be retrained by ED and clinical leads on what needs to be included in the patient's chart when transferring to another facility on 12/5/2023. All transfer charts will be audited by the ED and clinical leads prior to completing discharge to ensure that all relevant paperwork is included in the patient chart. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the receiving narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in one of one applicable record reviewed.
Patient # 5 was transferred to the facility on October 21, 2023 and was active at the time of the inspection.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be retrained in transfer documentation required to be present in the chart for transfers to the facility on 12/5/2023 by the ED. Intake chart audits will be completed within 7 days of admission by the clinical leads to ensure documentation is present |
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 ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in two of two applicable records reviewed.
Client # 7 was admitted on September 23, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 23, 2023; however, it was not completed prior to the date of the inspection.
Client # 8 was admitted on September 18, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on October 18, 2023 did not include any documentation that it was developed with the client.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will receive retraining in treatment planning and collaborative documentation on 12/7/2023 by the ED and clinical leads. Treatment plans will be reviewed by clinical leads to ensure that they are being completed with the patient present and in their own words. Services due this week reports will be run every Monday by the clinical leads to ensure that any treatment plans that are due are being completed. |
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 two of three applicable records reviewed.
Client # 1 was admitted on October 29, 2021 and was active at the time of the inspection. A treatment plan update was completed on August 17, 2023, and the next treatment plan update was due no later than October 17, 2023; however, no additional treatment plan updates were completed prior to the date of the inspection.
Client # 9 was admitted on October 8, 2021 and was active at the time of the inspection. A treatment plan update was completed on August 31, 2023, and the next treatment plan update was due no later than October 31, 2023; however, no additional treatment plan updates were completed prior to the date of the inspection.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All clinical staff will receive retraining in treatment planning documentation and timeframes on 12/7/2023 by the ED and clinical leads. Treatment plans will be reviewed by clinical leads to ensure that they are being completed with the patient present and in their own words. Services due this week reports will be run every Monday by the clinical leads to ensure that any treatment plans that are due are being completed. |
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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment, per the facility's policy, in two of three applicable records reviewed.
Client # 6 was admitted on January 26, 2023 and was discharged on October 23, 2023. The client record did not contain documentation of case consultation notes.
Client # 11 was admitted on July 1, 2022 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained on documentation timeframes on 12/7/2023 by the ED and clinical leads. Services due and Scheduled Events this week reports will be run every Monday by the clinical leads to ensure that any documentation due are being completed. |
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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30- and 60-days post discharge, per facility policy, in three of three applicable records reviewed.
Client # 3 was admitted on May 4, 2020 and was discharged on September 20, 2023. The client record did not contain documentation of follow-up information.
Client # 10 was admitted on June 1, 2023 and was discharged on September 15, 2023. The client record did not contain documentation of follow-up information.
Client # 13 was admitted on January 18, 2023 and was discharged on September 6, 2023. The client record did not contain documentation of follow-up information.
This is a repeat citation from the August 31, 2023 through September 1, 2023 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained on documentation timeframes on 12/7/2023 by the ED and clinical leads. Services due and Scheduled Events this week reports will be run every Monday by the clinical leads to ensure that any documentation due are being completed. |