INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 2 & 3, 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 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from February 2023 through September 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of March of 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) Facility Director and Health & Safety officer met on 12/8/23 and developed a secondary reminder system through Outlook Calendar. 2) Facility Director will monitor and provide back-up to Health & Safety Officer to ensure completion. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of ten client records reviewed. Client #10 was admitted on August 8, 2023 and was still active at the time of the inspection. Five release of information forms for funding sources, emergency contact, social service agency and a drug and alcohol facility dated October 5, 2023 did not have documentation that the client was offered a copy of the consent form. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1) Facility Director reviewed ROI completion requirements with all staff in Staff Meeting on 12/7/23. 2) All staff will completely review an ROI for completeness before signing or acting upon one going forward 3) Facility Director will spot check new ROIs monthly |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in two out of five applicable records reviewed.Patient #2 was admitted on May 4, 2022 and was still active at the time of the inspection. In July 2023, the patient only received two hours of psychotherapy. In August 2023, the patient only received two hours and fifteen minutes of psychotherapy. In September 2023, the patient only received forty-five minutes of individual and one hour and fifteen minutes of group psychotherapy. Patient #10 was admitted on August 8, 2023 and was still active at the time of the inspection. In September 2023, the patient only received one hour of individual psychotherapy. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patient #2 was short by 11 minutes in July 2023, they were over minimum by 17 minutes in September per EHR records. In July, group was ended early by a now-termed staff member and group requirements were addressed with that staff member at that time. As the primary counselor had just taken Patient #2 onto their caseload after the prior counselor terminated their employment, taking them over a full caseload, they were unable to accommodate any further time with Patient #2, but have since met or exceeded requirements with them.
With Patient #10, the primary counselor at the time failed to keep them accountable to the clinical requirements. This was addressed at the time. That staff member is no longer with the program.
1) Facility Director has primary responsibility and several resources by which to monitor patient hours and staff engagement with patients. These include tracking reports built into the EHR, as well as several corporate designed and maintained dashboards. These are reviewed weekly at minimum. 2) Clinical staff have access to the reports in the HR in order to track their own patients on an ongoing basis. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in four out of six applicable records reviewed.Patient # 2 was admitted on May 4, 2022 and was still active at the time of the inspection. The annual evaluation was due no later than May 4, 2023; however, there is no documentation that one was completed. Patient #4 was admitted on April 4, 2008 and was still active at the time of the inspection. An annual evaluation was completed on April 11, 2022. The next annual evaluation was due no later than April 11, 2023; however, it was not completed until April 14, 2023. Patient #7 was admitted on February 20, 2020 and was discharged on September 6, 2023. An annual evaluation was completed on January 31, 2022. The next annual evaluation was due no later than January 31, 2023; however, it was completed on February 23, 2023. Patient #9 was admitted on April 21, 2015 and was still active at the time of the inspection. An annual evaluation was completed on April 8, 2022. The next annual evaluation was due no later than April 8, 2023; however, it was completed on May 18, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Facility Director reviewed with MD & NP their process for scheduling annuals on 12/7 and 12/8/23 respectively; identified barriers to completion in a timely manner, primarily their schedules versus patients dosing schedules and patient resistance. 2) Front desk will begin scheduling the annuals a month prior. Facility Director will monitor effectiveness/compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation with all areas of regulation addressed within the regulatory timeframe in one out of six applicable records reviewed.Patient # 7 was admitted on February 20, 2020 and was discharged on September 6, 2023. An annual evaluation was completed on February 3, 2022. The annual evaluation was due no later than February 3, 2023; however, there is no documentation that one was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) As the failure was by a now-termed staff member, Facility Director reviewed process of reviewing charts transferred from other staff for completeness and necessity of completing any missing documentation and how to appropriately document the late completion with clinical staff during staff meeting on 12/7/23. 2) Facility Director will monitor compliance by spot checking chart and in individual supervision. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document that a medical history was obtain within 30 days of admission based on the facility ' s policy and procedures manual in two out of four applicable records reviewed. Client #6 was admitted on August 11, 2023 and was still active at the time of the inspection. A medical history was due no later than September 11, 2023; however, was not completed until September 23, 2023. Client #10 was admitted on August 8, 2023 and was still active at the time of the inspection. A medical history was due no later than September 8, 2023; however, it was not completed until October 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both documents were completed by a now-termed staff member who struggled with timely documentation. Company policy for addressing these issues were followed at that time.
Since that time Greenfield has employed the following steps: 1) ED reviewed standards for completion of biopsychosocial histories and assessments with all clinical staff in staff meeting and individual supervision. 2) ED oversees a monitoring process external to the EHR system to avoid this issue, both for document completion and treatment compliance of new patients. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document that a drug or alcohol history, or both was obtained within 30 days of admission based on the facility ' s policy and procedures manual in two out of four applicable records reviewed. Client #6 was admitted on August 11, 2023 and was still active at the time of the inspection. A drug or alcohol history, or both was due no later than September 11, 2023; however, one was not completed until September 23, 2023. Client #10 was admitted on August 8, 2023 and was still active at the time of the inspection. A drug or alcohol history, or both was due no later than September 8, 2023; however, one was not completed until October 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both documents were completed by a now-termed staff member who struggled with timely documentation. Company policy for addressing these issues were followed at that time.
Since that time Greenfield has employed the following steps: 1) ED reviewed standards for completion of biopsychosocial histories and assessments with all clinical staff in staff meeting and individual supervision. 2) ED oversees a monitoring process external to the EHR system to avoid this issue, both for document completion and treatment compliance of new patients. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document that a personal history was obtained within 30 days of admission based on the facility ' s policy and procedures manual in two out of four applicable records reviewed. Client #6 was admitted on August 11, 2023 and was still active at the time of the inspection. A personal history was due no later than September 11, 2023; however, was not completed until September 23, 2023. Client #10 was admitted on August 8, 2023 and was still active at the time of the inspection. A personal history was due no later than September 8, 2023; however, it was not completed until October 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both documents were completed by a now-termed staff member who struggled with timely documentation. Company policy for addressing these issues were followed at that time.
Since that time Greenfield has employed the following steps: 1) ED reviewed standards for completion of biopsychosocial histories and assessments with all clinical staff in staff meeting and individual supervision. 2) ED oversees a monitoring process external to the EHR system to avoid this issue, both for document completion and treatment compliance of new patients. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation within 30 days of admission based on the facility ' s policy and procedures manual in two out of four applicable records reviewed. Client #6 was admitted on August 11, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than September 11, 2023; however, was not completed until September 23, 2023. Client #10 was admitted on August 8, 2023 and was still active at the time of the inspection. A psychosocial evaluation was due no later than September 8, 2023; however, it was not completed until October 17, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both documents were completed by a now-termed staff member who struggled with timely documentation. Company policy for addressing these issues were followed at that time.
Since that time Greenfield has employed the following steps: 1) ED reviewed standards for completion of biopsychosocial histories and assessments with all clinical staff in staff meeting and individual supervision. 2) ED oversees a monitoring process external to the EHR system to avoid this issue, both for document completion and treatment compliance of new patients. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of nine records reviewed.Client #2 was admitted on May 4, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 16, 2023 and the next update was due no later than July 16, 2023; however, it was not completed until July 26, 2023. Client #3 was admitted on November 7, 2017 and was still active at the time of the inspection. A treatment plan update was completed on April 24, 2023 and the next update was due no later than June 24, 2023; however, it was not completed until June 26, 2023. The treatment plan update was completed on August 21, 2023 and the next update was due no later than October 21, 2023; however, it was not completed until October 23, 2023. Client #5 was admitted on March 2, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 23, 2023 and the next update was due no later than July 23, 2023; however, it was not completed until July 28, 2023.Client #9 was admitted on April 21, 2015 and was still active at the time of the inspection. A treatment plan update was completed on June 7, 2023 and the next update was due no later than August 7, 2023; however, it was not completed until August 9, 2023. The next treatment plan update was due no later than October 9, 2023; however, it was not completed until October 11, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director reviewed requirements for completion of treatment plan updates in 12/7/23 Staff Meeting. In addressing this area, it was reviewed that all patients must have completed treatment plans completed within 60 days of the previous update or from the comprehensive treatment plan based on creation date. Ongoing individual and group supervision will address progress in and completion of treatment plan updates to meet DDAP standards and regulations. This individual and group supervision as well as ensuring POC is followed through will be the responsibility of the Facility Director. Action steps and plan to address the completion of treatment plan updates in a timely manner are (1) Facility Director reviewed treatment plan updates in 12/7/23 Staff Meeting. (2) Monthly individual supervision will address completion of treatment plan updates and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and completion of treatment plan updates will be part of that review. (4) Education and training on timely completion of treatment plan updates will be part of group supervision and staff meetings. (5) Review of treatment plan updates will be a part of any IAuditor chart review and (6) Facility Director will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of two discharged records reviewed.Client #8 was admitted on October 12, 2021 and discharged on May 6, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1) Facility Director established and monitors a tracking system outside of the EHR for reminders for staff. 2) ED will ED will confirm in EHR that follow-ups are completed. 3) If former primary counselor can not complete the follow-up due to a scheduling conflict Facility Director will re-assign to another staff or complete themself. |