INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 28, 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-II, 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 (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.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed. Emergency exit doors were locked from the inside.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to have all exits unobstructed because of an exterior door being locked.
Exit door knob will be replaced with a keyed entry panic proof door knob that will allow for an unobstructed exit from the facility (panic proof functionality means the keyed entry function unlocks when door is opened from the inside allowing for an unobstructed exit at all times).
|
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.
|
Observations
Based on three of seven applicable patient records reviewed, the facility failed to provide documentation of a narcotic treatment program providing each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years.Patient # 1 was admitted on April 19, 2022 and was still active at the time of the inspection. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of :April 19- May 18- .45 minutesMay 19- June 18- .97 minutesJune 19- July 18- .75 minutesJuly 19- August 18- 0 hoursAugust 19- September 18- .43 minutesPatient # 5 was admitted on April 21, 2022 and was discharged August 4, 2022. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of :April 21- May 20- 0 hoursMay 21- June 20- 100 minutesJune 21- July 20- .50 minutesNo shows were documented June 20 and July 13Patient # 8 was admitted on October 8, 2022 and was discharged February 16, 2022. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of :October 8- November 7- .59 minutesNovember 8- December 7- 0January 8- February 7- .60 minutesNo shows were documented December 2 and December 28.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 16, 2021 annual licensing inspection.
|
Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for three of the reviewed charts.
The facility will ensure that all patients receive the required monthly psychotherapy hours. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Facility will return to pre-Covid group implementation and return to a treatment recommendation that includes a mix between individual and group clinical services.
Supervisory staff will retrain clinical staff on the appropriate way to document missed sessions and when patients have continued issues with session compliance.
Clinical Supervisor staff will have all clinical staff print out clinical compliance reports from the EMR and turn in week to check session compliance.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
|
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.
|
Observations
Based on two of two applicable patient records reviewed, the facility failed to provide documentation of admission date, medical and psychosocial summaries, exception requests, and current status of the patient when transferring the patient. Patient # 5 was admitted on April 21, 2022 and was discharged August 4, 2022. Patient # 5 was transferred to another facility on August 4, 2022. There was no documentation of the psychosocial summaries, dosage level, urinalysis reports or summary, or current status of the patient when transferring the patient. Patient # 8 was admitted on October 8, 2021 and was discharged February 16, 2022. Patient # 8 was transferred to another facility on February 16, 2022. There was no documentation of the psychosocial summaries of the patient when transferring the patient. These findings were reviewed with facility staff during the licensing process.
|
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 transferred to narcotic treatment program when appropriate. 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.
If prior release/consents have not been completed the facility will only transfer documents covered under the release/consent provided by the transferring facility. However, facility will make attempts to contact transferring facility to provide updated releases to include required documentation is to be sent.
Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
|
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on four of four applicable patient records reviewed, the facility failed to provide a complete patient record to include follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow up is to occur within 7 days, 3 months, and 12 months of the patient discharge. A follow-up will occur within 1 week of discharge if the patient is referred to another agency. Patient # 5 was admitted on April 21, 2022 and was discharged on August 4, 2022. There was no documentation of a follow-up in the patient record.Patient # 6 was admitted on May 30, 2018 and was discharged on May 20, 2022. There was no follow-up information documented in the patient record.Patient # 7 was admitted on December 16, 2021 and was discharged on April 27, 2022. There was no documentation of a follow-up in the patient record.Patient # 8 was admitted on October 8, 2021 and was discharged on February 16, 2022. There was no documentation of a follow-up in the patient record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 16, 2021 annual licensing inspection.
|
Plan of Correction
The facility failed to appropriately document discharge follow-ups in four record that was reviewed.
A new external tracking system has been implemented outside the current EMR to report and monitor completion of patient discharge follow-ups and facility will ensure that all clinical staff are appropriately trained on required discharge follow-up documentation.
The facility will ensure that all required discharge follow-ups are completed per facility policies/procedure manual.
Supervisory Staff will meet with program staff in treatment team meeting and review all requirements related to scheduling & completion of discharge follow-ups.
Supervisory & Compliance staff will continue to conduct monthly chart reviews which does include this aspect of the patient file.
|