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 1-2, 2021 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 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to keep the facility free of heaters that are not permanently mounted or installed. A physical plant inspection was conducted on March 1, 2021. At the time of the inspection, a portable heater was observed in the receptionist area.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Issue was addressed with staff member. At time of inspection they had been with the company less than 30 days and such devices were allowable by their prior employer. That section of the policy and procedure manual was re-reviewed with them and the device was removed. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate their treatment at the project in one of one client records.Client #7 was admitted on March 5, 2010 and was involuntarily terminated on August 28, 2020. There was no written notification of termination documented in client record #7.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the noted patient's termination from treatment this facility had changed over to a new EHR system just twenty days prior. There were numerous issues with documentation being missed as staff adjusted to the new system while also being work from home due to Covid-19. Those issues that could be returned to and corrected have been, and with use and continued training staff have adapted to the new system, however not every error could be corrected and some, as in the case of this chart were missed. Ongoing chart review have found no further issues of this type.
Since then and going forward all terminated patients will receive a written notification of termination and it will be documented in the patient chart. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of client records, the facility failed to document an onsite photograph of each patient in two of seven client records.Client #5 was admitted on May 4, 2020 and discharged on August 17, 2020. There was no onsite photograph documented in client record #5.Client #6 was admitted on July 28, 2020 and discharged on October 29, 2020. There was no onsite photograph documented in client record #6.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the workflow disruptions caused by Covid-19 and all of the clinical staff other than the ED being work from home issues of the facility's prior receptionist getting new patient photos at intake became ongoing. This has been resolved with the transition to the new EHR system (which includes an automated report of charts without photos), that receptionist retiring and being replaced by a new staff member, and returning the rest of the clinical staff to working in the office on either a permanent or rotating basis. All charts in the new EHR have photos and the identified charts have been corrected in the old system. |
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 client records, the facility failed to document it transferred client files to the receiving facility in one of one client records.Client #6 was admitted on July 28, 2020 and transferred to another treatment facility on October 29, 2020. There was no documentation that client #6's files were transferred to the receiving facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to Covid-19 the facility ED was the only clinical staff member onsite for much of 2020 and so had to handle anything for remotely working counselors that involved transfer of documents to other facilities. Recordings of those documents or uploading them into the EHR were missed. This was resolved starting in late November 2020 when counselors began doing one week rotations in clinic and assisting the ED with these day to day functions. In December we were able to bring back several counselors in office full time, allowing the work load to be spread around and reducing the rick of such errors.
With this movie towards normal functioning and going forward all records sent for a patient transfer will be documented in the patient chart. |