INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on April 24-25, 2012 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 4 PA Code and 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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715.20(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
Based on a review of patient records, the facility failed to document that they provided documentation to another facility when they transferred a patient to that facility in one of two patient records.
The findings include:
Twenty patient records were reviewed on April 24-25, 2012. Two of the patient records reviewed were transferred to another narcotic treatment facility. The transfer to another facility required the provision of patient records to the other narcotic treatment facility. There was no documentation that the facility provided this documentation in patient record #14.
Patient # 14 was admitted on February 7, 2007 and transferred to another narcotic treatment program on February 28, 2012. There was no documentation that the the transferring narcotic treatment program transferred patient records which included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient and contained the written consent of the patient.
The facility director and counselor were interviewed on April 25, 2012 and confirmed the findings.
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Plan of Correction
The facility director and clinical supervisor will provide training to clinical staff regarding the need for appropriate communication between other facilities, in the event of a patient transfer. The clinical staff will fax all requested documentation, within the bounds of confidentiality, to the facility that is requesting the information. Clinical staff will ensure that documentation/verification of the fax transmission is filed in the patient's record upon receipt. The Clinical Supervisor and the Facility Director will actively review the clinical records to ensure that requested records are being provided in a timely manner and that verification is being filed. The Clinical Supervisor and Facility Director will follow up with clinical staff regularly regarding this matter during individual supervision. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.
The findings include:
Three personnel records were reviewed for counselor qualifications. Three personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record #1.
Employee # 1 was hired as a counselor on April 23, 2012. The employee's Bachelor of Science degree was verified. There was no documentation of the employee's major.
The facility director was interviewed on April 25, 2012 and confirmed the findings.
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Plan of Correction
The facility director requested transcript on April 25, 2012 and since this time, the transcript has been received, verifying Counselor's degree. In the future the facility director will secure verification of education, prior to the employee beginning to serve the patients. |