INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Pinnacle Treatment Centers 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 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the stairways and exits are unobstructed.The physical plant inspection took place on April 23, 2021. At the time of the inspection, the exit stairs to the secondary exit were blocked off due to being in disrepair. They were unable to be used as they were unsafe and falling apart.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that the stairways and exits were unobstructed for easy exit.
The secondary exit from the build is in need of repair due to winter weather which cracked the stair stinger and rusted a way the screw fasteners.
There is currently a contract in place to replace/repair the secondary exit (steps/decking). Scheduling has been difficult to complete entire scope of work but will be able to complete needed work to make the secondary exit accessible by approved completion date.
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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 that client files were transferred to the receiving facility in one of one client records.Client #1 transferred into the facility on Ocotber 31, 2019. He transferred out of the facility on February 20, 2020. There was no documentation that the records for client #1 were transferred to the receiving facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to provide all the required documentation upon patients transfer to another narcotic treatment program.
The facility will ensure that all patients required documentation is provided to transferring narcotic treatment program when appropriate and with signed ROIs. The transferred documentation will also be imported into the electronic medical record.
When the facility has prior knowledge of potential patient transfers patient releases/consents will be completed in preparation to send required transfer documents.
However, if prior release/consents have not been completed the facility will only transfer documents covered under the release/consent provided by the transferring facility.
Facility started utilizing a new EMR as of September 2020 which provides an easier process to import external documentation into the system.
Supervisory staff will monitor this process and continue to conducted weekly chart reviews which does include this aspect of the patient file.
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