INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on February 6 - 8, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Centers PA-V, 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:
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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
The facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in fifteen of fifteen client records reviewed during the annual inspection conducted on February 6 - 8, 2018.
The consent to release information form included the following statement: "If I revoke this authorization, I need to do so in writing and mail or hand deliver it to the HIPAA Privacy Officer of the Pinnacle Provider Entity named above, at the address set forth above." The facility failed to adhere to the requirements in the federal confidentiality regulations by requiring the client to revoke the consent in writing in the following client records.
Client # 1 was admitted on August 15, 2017. The consents were signed by the client on August 15, 2017.
Client # 2 was admitted on August 17, 2017. The consents were signed by the client on August 17, 2017.
Client # 3 was admitted on October 24, 2017. The consents were signed by the client on October 24, 2017.
Client # 4 was admitted on July 6, 2015. The consents were signed by the client on July 7, 2017.
Client # 5 was admitted on August 8, 2017 and discharged October 30, 2017. The consents were signed by the client on August 8, 2017.
Client # 6 was admitted on April 20, 2017 and discharged August 8, 2017. The consents were signed by the client on April 20, 2017.
Client # 7 was admitted on December 6, 2016 and discharged December 5, 2017. The consents were signed by the client on November 20, 2017.
Client # 8 was admitted on February 5, 2009 and discharged July 21, 2017. The consents were signed by the client on February 2, 2017.
Client # 9 was admitted on October 14, 2016 and discharged November 7, 2017. The consents were signed by the client on October 13, 2017.
Client # 10 was admitted on June 9, 2015 and discharged October 27, 2017. The consents were signed by the client on June 6, 2017.
Client # 11 was admitted on July 17, 2012. The consents were signed by the client on July 17, 2017.
Client # 12 was admitted on March 7, 2017 and discharged May 5, 2017. The consents were signed by the client on March 7, 2017.
Client # 13 was admitted on March 11, 2014 and discharged January 4, 2018. The consents were signed by the client on March 10, 2017.
Client # 14 was admitted on April 28, 2009. The consents were signed by the client on April 24, 2017.
Client # 15 was admitted on September 8, 2016 and discharged on June 23, 2017. The consents were signed by the client on June 15, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Assurance Director and the Legal Team have developed a new Release of Information template. This new template states that the authorization can be revoked at any time in writing and/or verbally. The Quality Assurance Director submitted the new template to our EMR and the form is currently being utilized. The Facility Director has reviewed this form in our EMR. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility's narcotic treatment physician failed to document the review of patient dosage levels at least twice a year in eight of eight patient records reviewed during the annual inspection conducted on February 6 - 8, 2018.
Patient dosage reviews were documented by the facility's Physician Assistant in the following patient records:
Patient # 4 was admitted on July 6, 2015. The dosage reviews were documented on June 19, 2017 and January 4, 2018.
Patient # 7 was admitted on December 6, 2016 and discharged December 5, 2017. The dosage review was documented on June 1, 2017.
Patient # 8 was admitted on February 5, 2009 and discharged July 21, 2017. The dosage review was documented on January 27, 2017.
Patient # 9 was admitted on October 14, 2016 and discharged November 7, 2017. The dosage reviews were documented on April 10 and October 4, 2017.
Patient # 10 was admitted on June 9, 2015 and discharged October 27, 2017. The dosage review was documented on June 1, 2017.
Patient # 11 was admitted on July 17, 2012. The dosage reviews were documented on July 10, 2017 and January 4, 2018.
Patient # 13 was admitted on March 11, 2014 and discharged January 4, 2018. The dosage reviews were documented on March 9 and September 6, 2017.
Patient # 14 was admitted on April 28, 2009. The dosage reviews were documented on April 24 and October 4, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will meet with the medical director, physician, and physician assistant to review the policy on Medication Dosage with regard to dose reviews. At the start of each month, the physicians will run a report to determine which patients are in need of a dose review. All dosage reviews will then be completed by the physician by the identified date. At the end of each month, the facility director will complete chart audits making sure that dose reviews are being completed by the physicians. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The narcotic treatment physician failed to determine the proper dosage level for a patient by writing standing orders for the patient's induction phase in three of seven patient records reviewed during the annual inspection conducted on February 6 - 8, 2018.
Patient # 1 was admitted on August 15, 2017. The physician ordered 20 mg, 25 mg and then 30 mg on August 15, 2017.
Patient # 5 was admitted on August 8, 2017. The physician ordered 20 mg, 25 mg and then 30 mg on August 8, 2017.
Patient # 6 was admitted on April 20, 2017 and discharged on August 8, 2017. The physician ordered 25 mg, 30 mg and then 35 mg on August 8, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will conduct a training for the narcotic treatment physicians on methadone admission, dosing and induction practices. The narcotic treatment physicians will not place standing orders for patient's initial dosing. To ensure compliance, the facility director will complete chart audits on new intakes. |
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
The facility's medical director failed to review, date and sign an annual evaluation of each patient's status in three of seven patient records reviewed during the annual inspection conducted on February 6 - 8, 2018.
Patient # 4 was admitted on July 6, 2015. The annual evaluation was completed on July 6, 2017.
Patient # 9 was admitted on October 14, 2016 and discharged November 7, 2017. The annual evaluation was completed on October 13, 2017.
Patient # 13 was admitted on March 11, 2014 and discharged January 4, 2018. The annual evaluation was completed on March 10, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will meet with the medical director to review the policy on annual evaluations. All annual evaluations will be reviewed, dated, and signed by only the medical director of the facility. To ensure compliance of this policy, the facility director and the physician assistant will complete chart audits on a bi-weekly basis. |