INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 13-14, 2022 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 - VIII, LLC 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month.
The fire drills conducted between July 2021 and March 2022 were reviewed and there was no fire drill documented for the month of October 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Executive Director will designate an internal staff member to assist with all Health and Safety protocols in the facility and this will include fire drills. Staff member along with Executive Director will ensure Monthly fire drills are being completed,and that they are documented/recorded internally in our Electronic Record System. This will begin Immediately as of 4/16/2022. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill logs, the facility failed to utilize alternate exit routes during fire drills.
All of the fire drills conducted between July 2021 and March 2022 were reviewed and the front door was documented as the exit route used for every fire drill conducted during that time period. No alternate exit route was documented.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Executive Director will designate an internal staff member to assist with all Health and Safety protocols in the facility and this will include fire drills. Staff member along with Executive Director will ensure alternate exit routes are being utilized,and that they are documented/recorded internally in our Electronic Record System. This will begin Immediately as of 4/16/2022, and will be ongoing. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of an agent in one of six client records.
Client #2 was admitted and medicated on January 24, 2022. The informed consent was signed by client #2 on January 31, 2022 and the first medication dose was administered on January 24, 2022.
These findings were reviewed with staff during the licensing inspection.
|
Plan of Correction
Executive Director and Medical peronal held a meeting to go over what informed consent means and when it needs to be signed. After Medical Team meets with patient for and intake, and all paperwork has been submitted. We will review completed submissions and sign off on all forms that need signed. When this has occurred, our dosing nursing will also check all forms in Methasoft to ensure documents (informed consent) has been completed and signed off on. This will begin as of 4/16/2022, and will be ongoing. |
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.
|
Observations
Based on a review of patient records, the facility failed to document an annual evaluation of each patient's status that was reviewed, dated and signed by the medical director in one of two patient records.
Patient #7 was admitted on January 9, 2019 and discharged on March 4, 2022. There was no annual evaluations documented in patient record #7.
These findings were reviewed with facility staff during the inspection.
|
Plan of Correction
Executive Director and Clinical Supervisor from Charleroi Treatment services will ensure documentation of time required annual evaluations. Clinical Supervisor will utilize tracking form of due dates,specifically annual reviews, and place holds on appropriate patients. Clinical Supervisor and Executive Director will retrain staff on regulations pertaining to evaluations,to ensure documentation is being met and signed off in a timely manner. This will begin immediately 4/16/2022 and continue thereafter. |