INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 27-28, 2024, 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-IV, LLC dba Summit Treatment Services 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of ten records.
Client #5 was admitted to the outpatient level of care on June 25, 2020 and was transferred to another facility on February 23, 2024. Client #5 ' s record showed confirmation that their record was sent to the receiving facility. However, there was no informed and voluntary consent from the client for the disclosure of information to the receiving facility contained in the record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor will review the transfer out process and compliance in doing so in the upcoming 9/18 clinical staff meeting. Facility Director will also address this with medical staff in next group supervision. In addressing this area, it will be reviewed that when information is sent to another facility in the transfer process (or at any time), a valid release of information must be obtained to do so.
Ongoing individual and group supervision will address progress in and completion of release of informations to meet DDAP and HIPAA standards and regulations. This indivual and gorup supervision as well as ensuing POC being followed through will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of releases of information/consents to meet DDAP and HIPAA standards are (1) Summit Clinical Supervisor will review the release of information/consent process in the 9/18/24 clinical staff meeting, (2) Facility Director will meet with and review the release of information/consent process when a patient transfers out in the next group meeting with medical staff (3) Monthly individual supervision will address the release of information/consent process and barriers to meeting this regulation. (4) Individual patient charts will be reviewed during some individual supervision sessions and completion necessary releases of information, especially in the transfer process, will be part of the group supervision and other staff meetings. (5) Facility Director, when reviewing the discharge process of patients that are transferring, will review the chart to ensure the necessary releases of information or completed and scanned into the EMR. (6) Facility Director will track transfers from Summit to other facilitites and review with Clinical Supervisor monthly to ensure all ROI's are being completed. (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations within the facility ' s identified policy time frames of at three months, six months, and nine months, and then yearly in two of four applicable client records.
Client #4 was admitted to the outpatient level of care on January 10, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 10, 2024. However, no case consultation was found in client #4 ' s record.
Client #10 was admitted to the outpatient level of care on January 29, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 29, 2024. However, no case consultation was found in client #10 ' s record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 1, 2023 and September 13, 2023 licensing inspections.
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Plan of Correction
Summit Clinical Supervisor will review case consult procedure and compliance in the upcoming 9/18 clinical staff meeting. In addressing this area, it will be reviewed that all patients must have case consults completed by the 3-month, 6-month, 9-month and 12-month mark in the first year and annually after the first year.
Ongoing individual and group supervision will address progress in and completion of case consults to meet DDAP standards and regulations. This indivual and gorup supervision as well as ensuing POC being followed through will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of case consults are (1) Summit Clinical Supervisor will review case consults and case consult procedure in 9/18/24 clinical staff meeting. (2) Monthly individual supervision will address completion of case consults and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during some individual supervision sessions and completion of case consults will be part o fthe group supervision and other staff meetings. (4) Clinical Supervisor and Facility Director will meet monthly to review EHR reports on case consult completion to ensure compliance. (5) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting case consultation notes was submitted and approved by the Department for the February 1, 2023 and the September 13, 2023 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the August 27-28, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action steps and plan to address this deficiency. (1) The Facility Director will ensure the plans of correction are implemented by the corrective action date and clinical supervisor will assist in the monitoring process. (2) Additional monitoring will occur through chart audits completed by the PTC Quality compliance team and if deficiencies are noted they will be reviewed within the month. (3) Clinical supervisor, Quality compliance staff, and Facility Director will monitor continued implementation of the plan through quarterly supervisor meetings designed to address this area and will meet monthly to review EHR reports on case consult completion to ensure compliance. (4) If the plan of correction appears to be not working as written, a supervisory meeting will occur to adjust the current plans. The Facility Director will report to the project director the findings each quarter during PTCs regional operations meeting. |