INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on March 16 & 19, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document monthly fire drills that included whether the fire alarm or smoke detector was operative. Fire drill logs from April 2019 to February 2020 were reviewed on March 16 & 19, 2020. The fire drill logs did not include documentation of whether the fire alarm or smoke detector was operative. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Verification of testing of smoke detectors and fire alarm system have been added to fire drill reports effective 4/1/10. These tests will be completed by the facility Health and Safety officer as assigned by the Executive Director. Compliance will be reviewed by the Executive Director monthly. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to have a narcotic treatment physician make a face to face determination of current physiologically dependent upon a narcotic drug and has been dependent for at least one year, in one of seven patient records.Ten patient records were reviewed om March 16, 2020. Seven were reviewed for the face to face documentation. In patient record # 3, the certified nurse practitioner completed the face to face determination. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 3/16/2020 only the facility Medical Director is completing the face to face determination as verified by the facility Executive Director. However, an exception will be filed to allow the Certified Registered Nurse Practitioner to do so as she is independently DEA certified. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Ten patient records were reviewed on March 16, 2020. Four were reviewed for the semi-annual dose review. In patient record # 4, the certified nurse practitioner documented and signed the semiannual dose review on February 20, 2020.In patient record # 6, the certified nurse practitioner documented and signed the semiannual dose review on September 5, 2019.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 3/16/2020 only the facility Medical Director the semi-annual dose review. This is monitored for compliance by the facility Executive Director. |
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 have a narcotic treatment physician determine the patient ' s initial dose in one of seven records.Ten patient records were reviewed on March 16, 2020. Seven were reviewed for the patient ' s initial dose. In patient record #3, the certified nurse practitioner ordered and signed the patient's initial dose on February 19, 2020. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 3/16/2020 only the facility Medical Director is ordering and signing for the initial dose. This will be monitored for compliance by the facility Executive Director. However, an exception will be filed to allow the Certified Registered Nurse Practitioner to do so as she is independently DEA certified. |