INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 12 & 13, 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 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.Client #10 was admitted on March 2, 2015 and discharged on June 21, 2023This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed process of notifying patients of involuntary termination in writing in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. In addressing this area, it was reviewed that for each involuntary termination, a written termination notice must be given/sent to patient. This notice letter is located in Methasoft forms.
A review of each involuntary discharge will occur to address and ensure that each patient receiving an involuntary termination receives notice of involuntary termination in writing and this notice meets all DDAP standards and regulations. This will be the responsibility of both the Facility Director and Clinical Supervisor.
Action steps and plan to address the completion of the written notice of termination for patients who are involuntarily discharged from services are (1) Summit Clinical Supervisor reviewed process of notifying patients of involuntary termination in writing in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (2) Once decision is made of the need for involuntary termination, both the Clinical Supervisor and Facility Director will ensure a written notice of termination is given/sent to patient and it is documented appropriately. (3) Facility Director, Clinical Supervisor and Lead Counselor will monitor that this procedure is followed for each involuntary termination in random chart audits through Iauditor and (4) Facility Director and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
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 three applicable records reviewed.Patient #4 was admitted on April 18, 2023 and was still active at the time of the inspection. In May 2023, the patient received only one hour of individual therapy and one hour and fifteen minutes of group therapy. In June 2023, the patient received forty-five minutes of individual therapy and one hour of group therapy. In July 2023, the patient only received one hour and fifteen minutes of group therapy and zero hours of individual therapy. In August 2023, the patient only received fifty minutes of individual therapy and one hour and fifteen minutes of group therapy. Patient # 6 was admitted on May 17, 2023 and was still active at the time of the inspection. In June, the patient only received forty-five minutes of individual therapy and one hour and fifteen minutes of group therapy. In July 2023, the patient only received one hour and fifteen minutes of group therapy and zero hours of individual therapy hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed requirements for counseling hours of patients in their first 2 years in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. In addressing this area, it was reviewed that all patients in their first 2 years in treatment are required to meet 2.5 hours of individual and group counseling.
Ongoing individual and group supervision will address progress in and completion of counseling hours 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, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of individual and group counseling totaling 2.5 hours/month are (1) Summit Clinical Supervisor reviewed counseling requirements in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (2) Monthly individual supervision will address counseling requirements met and barriers to meeting these requirements. (3) Individual patient charts will be reviewed during specific individual supervision sessions and counseling requirements will be discussed. (4) Education and training on time management and ensuring counseling requirements are met will be part of group supervision and staff meetings. (5) Counseling requirements will be reviewed and monitored with random chart audits completed and (6) Facility Director and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 one hour of group or individual therapy every other month after four years of treatment in one out of four applicable records.Patient #10 was admitted on March 2, 2015 and discharged on June 21, 2023. In March 2023, the patient only received forty-five minutes of individual therapy and zero hours of group therapy. In May 2023, the patient only received thirty minutes of individual therapy and zero hours of group therapy. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed requirements for counseling hours of patients after 4 years in treatment in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. In addressing this area, it was reviewed that all patients after 4 years in treatment are required to meet 1 hour of individual or group counseling every other month.
Ongoing individual and group supervision will address progress in and completion of counseling hours 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, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of individual and group counseling for patients after 4 years of treatment totaling 1 hour every other month are (1) Summit Clinical Supervisor reviewed counseling requirements in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (2) Monthly individual supervision will address counseling requirements met and barriers to meeting these requirements. (3) Individual patient charts will be reviewed during specific individual supervision sessions and counseling requirements will be discussed. (4) Education and training on time management and ensuring counseling requirements are met will be part of group supervision and staff meetings. (5) Counseling requirements will be reviewed and monitored with random chart audits completed and (6) Facility Director and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
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 physical by the narcotic treatment physician within the regulatory timeframe in one out of four applicable records reviewed.Patient #10 was admitted on March 2, 2015 and discharged on June 21, 2023. An annual physical was completed on February 28, 2022. The next annual physical was due no later than February 28, 2023; however, was completed on March 15, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed ensuring MD/PA completes annual physicals in a timely manner in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. In addressing this area, it was reviewed that annual physicals are done annually, no more than 365 days from previous annual physical.
Summit's MD and the PA's complete the annual physical process for each patient. Completion of annual physicals can be addressed in supervision and in staff meetings.
Compliance in this area will be the responsibility of the MD and PA's to ensure completion and the Facility Director and Clinical Supervisor to ensure compliance in the chart.
Action steps and plan to address the completion annual physicals per DDAP regulations are (1) Summit Clinical Supervisor reviewed process of timely completions of Annual physicals in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (2) Medical Director will review with PA's the proper and timely completion of annual physicals in supervision sessions. (3) Facility Director, Clinical Supervisor and Lead Counselor will monitor that annual physicals are completed through chart auditing process through Iauditor and (4) Facility Director and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
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 within the regulatory timeframe in two out four applicable records reviewed.Patient #5 was admitted on April 30, 2020 and was still active at the time of the inspection. The annual evaluation was due no later than April 30, 2023; however, was not completed until May 18, 2023.Patient #10 was admitted on March 2, 2015 and discharged on June 21, 2023. An annual evaluation was completed on February 28, 2022. The next annual evaluation was due no later than February 28, 2023; however, there is no documentation that one was completed at the time of the inspection. This is a repeat citation from the February 1, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed requirements for annual evaluations being completed in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. In addressing this area, it was reviewed that all patients must have annual evaluations completed annually, no more than 365 days from the previous annual evaluation completed.
Ongoing individual and group supervision will address progress in and completion of annual evaluations 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, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of annual evaluations are (1) Summit Clinical Supervisor reviewed timely completion of annual evaluations in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (2) Monthly individual supervision will address completion of annual evaluations and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and completion of annual evaluations will be part of that review. (4) Education and training on timely completion of annual evaluations will be part of group supervision and staff meetings. (5) Facility Director and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures that a comprehensive treatment plan must be completed within 30 days of admission in two out of four applicable records reviewed. Client #1 was admitted on August 9, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than September 9, 2023; however, was not completed until September 12, 2023.Client #6 was admitted on May 17, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 17, 2023; however, was not completed until June 22, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed requirements for completion of comprehensive treatment plans in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. In addressing this area, it was reviewed that all patients must have comprehensive treatment plans completed within 30 days of admittance.
Ongoing individual and group supervision will address progress in and completion of comprehensive treatment plans 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, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of comprehensive treatment plans in a timely manner are (1) Summit Clinical Supervisor reviewed comprehensive treatment plans in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (2) Monthly individual supervision will address completion of comprehensive treatment plans and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and completion of comprehensive treatment plans will be part of that review. (4) Education and training on timely completion of comprehensive treatment plans will be part of group supervision and staff meetings. (5) Review of comprehensive treatment plans will be a part of any IAuditor chart review and (6) Facility Director and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
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 five out of ten applicable records reviewed.Client #2 was admitted on December 15, 2022 and was discharged on August 25, 2023. A treatment plan update was completed on March 3, 2023, and the next update was due no later than May 3, 2023; however, it was not completed until May 16, 2023. Client #3 was admitted on January 8, 2020 and was still active at the time of the inspection. A treatment plan update was completed on March 15, 2023, and the next update was due no later than May 15, 2023; however, it was not completed until May 30, 2023. Client #5 was admitted on April 30, 2020 and was still active at the time of the inspection. A treatment plan update was completed on April 26, 2023, and the next update was due no later than June 26, 2023; however, it was not completed until June 29, 2023.Client #10 was admitted on March 2, 2015 and was discharged on June 21, 2023. A treatment plan update was completed on March 13, 2023, and the next update was due no later than May 13, 2023; however, there is no documentation that one was completed. Client #11 was admitted on July 24, 2019 and was still active at the time of the inspection. A treatment plan update was completed on May 12, 2023, and the next update was due no later than July 12, 2023; however, it was not completed until July 24, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed requirements for completion of treatment plan updates in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. 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.
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, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the completion of treatment plan updates in a timely manner are (1) Summit Clinical Supervisor reviewed treatment plan updates in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (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 and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |
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 the 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 six out of nine applicable client records. Client #3 was admitted on January 8, 2020 and was still active at the time of the inspection. A case consultation was due no later than January 2023; however, was not completed until August 22, 2023.Client #4 was admitted on April 18, 2023 and was still active at the time of the inspection. A case consultation was due no later than July 18, 2023; however, there was no documentation that one was completed. Client #5 was admitted on April 30, 2020 and was still active at the time of the inspection. A case consultation was due no later than April 30, 2023; however, it was not completed until May 18, 2023.Client #6 was admitted on May 17, 2023 and was still active at the time of the inspection. A case consultation was due no later than August 17, 2023; however, there was no documentation that one was completed. Client #10 was admitted on March 2, 2015 and discharged on June 21, 2023. A case consultation was completed on March 16, 2022, and the next case consultation was due no later than March 16, 2023; however, there was no documentation that one was completed. Client #11 was admitted on July 24, 2019 and was still active at the time of the inspection. A case consultation was completed on August 1, 2022, and the next case consultation was due no later than August 1, 2023; however was not completed until August 17, 2023. This is a repeat citation from the February 1, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed requirements for case consults being completed in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. In addressing this area, it was reviewed that all patients must have case consults done 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 individual and group supervision as well as ensuring POC is 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 reviewed case consults in 9/20/23 Clinical Meeting and Clinical Supervisor/Facility Director will review in 10/4 /23 staff meeting as well. (2) Monthly individual supervision will address completion of case consults and barriers to meeting this regulation. (3) Individual patient charts will be reviewed during specific individual supervision sessions and completion of case consults will be part of that review. (4) Education and training on timely completion of case consults will be part of group supervision and staff meetings. (5) Facility Director and Clinical Supervisor will address any issues with noncompliance in this area through continued training in clinical and staff meetings. |