INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 26 - 27, 2018 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Pinnacle Treatment Center PA-VI, LLC dba Greenfield Counseling 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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715.17(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
The facility failed to document that for each new patient enrolled in the program, the initial dose of methadone did not exceed 30 milligrams.Seven newly admitted patient records were reviewed on April 26 -27, 2018. Each new patient enrolled in the program is to have an initial dose of methadone not to exceed 30 milligrams. Patients #3 and #6 had an initial dose which exceed 30 milligrams.Patient #3 was admitted on January 2, 2018 and was given an initial dose that day. The medication order, dated January 2, 2018, stated the patient was to receive 40 milligrams as the initial dose.Patient #6 was admitted on November 7, 2017 and was given an initial dose that day. The medication order, dated November 7, 2017, stated the patient was to receive 55 milligrams as the initial dose.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regulation was reviewed with all staff by the Regional Director in staff meeting. Going forward, required medical files will be transferred from the correctional facility and/or transferring OTP and will be scanned into the EHR by the intake counselor.
Further, the Physician will include a justification of any initial dose exceeding 30mg in his intake note. The Facility Director will be responsible to review these issues for compliance during the weekly chart review process. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facility failed to document that it transferred patient files in two of two transferred patient records.Two transferred patient records were reviewed on April 26-27, 2018. Patient records #4 and #7 did not include documentation of of transferred patient files.Patient #4 was admitted on April 21, 2017 and transferred on September 22, 2017. There was no documentation of the patient's file being transferred even though there was a signed release of information for the new facility. Patient #7 was admitted on December 14, 2017 and transferred on February 18, 2018. There was no documentation of the patient's file being transferred even though there was a signed release of information for the new facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regional Director reviewed the regulatory requirements with all staff. Releases for required patient records will be obtained from the patient at intake. The release will be sent to the transferring facility requesting that required records be sent. Documentation of the request will be kept in the patient records. Once recieved, information will be reviewed and scanned into the EHR. Intake staff will be responsible to document the request and assigned counselors will be reposnsible for scanning the information into the EHR.
The Facility Director will review all transferring patient files for completed releases, documentation of the request, and follow up scanned information during weekly chart audits.
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