INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 23-24, 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-VIII, 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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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of unusual incident reports, the facility failed to document that DDAP was notified within 3 business days following a client death.
Nine client deaths were reported to have occurred in the last licensing year, April 2022 - February 2023. There was no documentation that seven of the nine client deaths were reported to DDAP within three business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Executive Director will notify Regional Director when unusual incident had occurred within 24 hrs. of incident. Executive Director will submit unusual incident VIA IAuditor internal report for review and guidance of information given. 2.Executive will implement this to begin ASAP and provide training to Clinical Supervisor in the case if Executive Director is not available to complete.
3.Education was provided by inspector to Executive Director and Clinical Supervisor of correct web address to use for these specific incidents moving forward. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document a random monthly urinalysis in two of seven patient records.
Patient #2 was admitted on July 11, 2022 and is currently an active patient. There was no random monthly urinalysis documented for October 2022 in patient record #2.
Patient #6 was admitted on September 13, 2021 and discharged on January 24, 2023. There was no random monthly urinalysis documented for October 2022 in patient record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Executive Director and Clinical Supervisor will meet individually with Clinical staff to train staff on how locate monthly urine screen in Methasoft, and how to schedule the urine screen within Methasoft, if one had been missed. Executive Director and Clinical Supervisor will also provide education on Clinical Science Lab, which we use for testing, and provide username and password, to ensure screens have been completed and uploaded into Methasoft. Executive Director and Clinical Supervisor will delegate staff member to check urine screens that have been submitted week prior at the facility and print off and give to each staff members according to their specific caseloads. 2.Executive Director and Clinical Supervisor will implement this beginning 3/1/2023, to ensure all urine screens have been submitted, and uploaded into Methasoft. Clinical Supervisor will monitor monthly moving forward. |