INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 14 & 15, 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 Center 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of nine personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #5 was hired on July 3, 2023 as a counselor assistant. Employee # 5 has a bachelor ' s degree with no experience and may counsel clients only under close supervision of a trained counselor or clinical supervisor for the first 6 months of employment. Employee #5 did not receive formal case review during supervision occurring on August 4, 8, 10, 17, 23, 31, September 7, 8, 14, 21, 29, and October 20 and 27, 2023 and there was no documentation that direct observation occurred. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Based on a review of the supervision notes there is no documented formal case review for the first six months of employment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA Executive Director reviewed Clinical Supervisor as well as Lead counselor the expectations and regulations of hiring a Counselor Assistant with no prior experience. This was reviewed in the weekly supervisor meeting on 11/21/23. Executive Director will monitor the progress of making up the hours of case consultation and direct supervision in weekly meetings and ongoing with all new counselor assists
In this review, it was explained that PTSA Clinical supervisor needs to provide 1 hour of case consultation and 1 hour of direct supervision of all counselor assistants weekly. This will be reviewed weekly moving forward for ongoing compliance.
Action step:
1. Clinical Supervisor will provide 3 hours of supervision per week to employee #5 until all supervision is made of from what was missed.
Clinical Supervisor will provide 1 hour of direct supervision and 1 hour of case consultations weekly to all counselor assistants.
2. Executive Director will monitor the progress of supervision to ensure that the time is being made up and done correctly moving forward.
3. Education and training will be ongoing in all supervisor meetings weekly.
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of ten client records reviewed.
Client #10 was admitted on April 21, 2016 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a financial institute dated November 1, 2023 was offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
PTSA clinical Supervisor reviewed requirements of Confidenality and the completion of consents to release information correctly on the 11/20/23 Clinical Staff meeting. Clinical Supervisor will review with Executive Director in supervisor meeting on 11/27/23 the outcome. It was addressed that all consents to release are completed correctly prior to releasing information to any outside source.
Clinical Supervisor will hold weekly clinical and medical meetings to address progress of meeting this expectation to align with DDAP regulations.
Executive Director will monitor weekly progress to ensure POC action steps are being followed to ensure compliance.
Action Steps
1. PTSA clinical supervisor reviewed (11/20/23 )how to complete a consent correctly and demonstrated how to complete. An example was provided to all staff.
2. Monthly individual supervision will address how to complete a consent correctly.
3. Individual Patient charts will be reviewed during supervision to check compliance.
4. Education and training will be provided in clinical and medical meetings to ensure ongoing compliance.
5. Executive Director will address any barriers with compliance to this regulation in supervision, trainings, and improvement plans. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of a review of the physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of June 4-10, 2023, the patient census was 304. The facility was required to provide at least 30.4 physician hours. There were only 18.63 physician hours documented.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
PTSA Executive Director reviewed Physician staffing requirements in a meeting with the medical staff on 11/22/23. In this review, it was explained that PTSA needs to provide 1 hour of Physician time per 10 patients. This will be reviewed weekly moving forward for ongoing compliance.
Action step:
1. Executive Director will review staffing and schedules 1 month in advance for vacation coverage to ensure compliance with this regulation.
2. Executive Director will utilize additional staff physician for additional hours for coverage to cover all vacations and holiday weeks.
3. Education and training will be ongoing in all supervisors medical staff in monthly meetings.
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
During the week of May 28-June 3, 2023, the patient census was 304. The physician was required to provide one-third of the 30.4 hours, which equals to 10.03 hours. The physician only provided 7.5 hours.
During the week of June 18-24, 2023, the patient census was 303. The physician was required to provide one-third of the 30.3 hours, which equals 9.99 hours. The physician only provided 7.75 hours.
During the week of July 2-8, 2023, the patient census was 304. The physician was required to provide one-third of the 30.4 hours, which equals 10.03 hours. The physician only provided 8 hours.
During the week of September 3-9, 2023, the patient census was 305. The physician was required to provide one-third of the 30.5 hours, which equals 10.06 hours. The physician only provided 7.75 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA Executive Director reviewed Physician Assistant staffing requirements in a meeting with the medical staff on 11/22/23. In this review, it was explained that PTSA needs to provide 1 hour of Physician time per 10 patients however 2/3 of this time can be provided by the Physician Assistant. This will be reviewed weekly moving forward for ongoing compliance.
Action step:
1. Executive Director will review Physician and Physician Assistant staffing and schedules 1 month in advance for vacation coverage to ensure compliance with this regulation.
2. Executive Director will utilize additional staff physician and Physician Assistant for additional hours for coverage to cover all vacations and holiday weeks.
3. Education and training will be ongoing in all supervisors medical staff in monthly meetings.
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter in one out of ten records reviewed.
Patient # 4 was admitted on July 31, 2023 and was still active at the time of the inspection. There was no documentation that a urinalysis was completed in August or September 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA Clinical Supervisor and Executive director reviewed urinalysis testing in e 11/20/23 clinical and medical staff meeting. This will be reviewed weekly and monthly moving forward for ongoing compliance. In addressing this regulation, it was reviewed that all patient must have a minimum of 1 drug screen per month. Executive Director will review with supervisors weekly in supervisor meeting to ensure ongoing compliance.
Action step:
1. Clinical Supervisor will review in Individual and Group supervision the ongoing expectations based on this DDAP regulation of urinalysis.
2. Individual Charts will be pulled and reviewed at random in individual and group supervisors to ensure compliance and follow through of POC.
3. Education and training will be ongoing in all supervisors and staff meetings
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed.
5. Executive Director will develop a secondary tracking system for the medical staff to ensure compliance. |
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 five out of five applicable records reviewed.
Patient # 1 was admitted on February 8, 2023 and was still active at the time of the inspection. In September and October 2023, the patient did not receive any psychotherapy.
Patient #4 was admitted on July 31, 2023 and was still active at the time of the inspection. In August, September and October 2023, the patient did not receive any psychotherapy.
Patient #5 was admitted on June 27, 2023 and was still active at the time of the inspection. In July and September 2023, the patient received did not receive any psychotherapy.
Patient #6 was admitted on August 21, 2023 and was still active at the time of the inspection. In September 2023, the patient did not receive any psychotherapy.
Patient #9 was admitted on December 9, 2021 and was still active at the time of the inspection. In October 2023, the patient only received one hour of individual psychotherapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA Clinical Supervisor reviewed clinical time requirements for counseling hours in the 11/20/23 clinical staff meeting. This will be reviewed weekly and monthly moving forward for ongoing compliance. In addressing this regulation, it was reviewed that all patients within their first 2 years of treatment need to be provided 2.5 hours per month at minimum for counseling in the form of individual and group. Executive Director will review with supervisors weekly in supervisor meeting to ensure ongoing compliance.
Action step:
1. Clinical Supervisor will review in Individual and Group supervision the ongoing expectations based on this DDAP regulation of 2.5 hours per month.
2. Individual Charts will be pulled and reviewed at random in individual and group supervisors to ensure compliance and follow through of POC.
3. Education and training will be ongoing in all supervisors and staff meetings
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 at least one hour per month of group or individual psychotherapy during the third and fourth year of treatment in one out of one applicable record.
Patient #8 was readmitted on May 22, 2023 and was still active at the time of the inspection. In September and October 2023, the patient did not receive any psychotherapy.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA Clinical Supervisor reviewed clinical time requirements for counseling hours in the 11/20/23 clinical staff meeting. This will be reviewed weekly and monthly moving forward for ongoing compliance. In addressing this regulation, it was reviewed that all patients within their year 3 and 4 of treatment need to be provided 1 hours per month at minimum for counseling in the form of individual and group. Executive Director will review with supervisors weekly in supervisor meeting to ensure ongoing compliance.
Action step:
1. Clinical Supervisor will review in Individual and Group supervision the ongoing expectations based on this DDAP regulation of 1 hours per month.
2. Individual Charts will be pulled and reviewed at random in individual and group supervisors to ensure compliance and follow through of POC.
3. Education and training will be ongoing in all supervisors and staff meetings
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed. |
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 every other month of psychotherapy after four years of treatment in one out of four applicable records.
Patient #7 was admitted on July 9, 2014 and discharged on March 2023. In January and February 2023, the patient did not receive any psychotherapy.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA Clinical Supervisor reviewed clinical time requirements for counseling hours in the 11/20/23 clinical staff meeting. This will be reviewed weekly and monthly moving forward for ongoing compliance. In addressing this regulation, it was reviewed that all patients within their 4th year or more of treatment need to be provided 1 hours of clinical time every other month in the form of individual and/or group. Executive Director will review with supervisors weekly in supervisor meeting to ensure ongoing compliance.
Action step:
1. Clinical Supervisor will review in Individual and Group supervision the ongoing expectations based on this DDAP regulation of 1 hour every other month.
2. Individual Charts will be pulled and reviewed at random in individual and group supervisors to ensure compliance and follow through of POC.
3. Education and training will be ongoing in all supervisors and staff meetings
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed. |
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 five applicable records reviewed.
Patient #2 was admitted on July 13, 2015 and was still active at the time of the inspection. An annual physical was completed on September 14, 2022. The next annual physical was due no later than September 14, 2023; however, it was completed on September 20, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA clinical Supervisor reviewed requirements for completion of Annual Physicals on the 11/20/23 Clinical Staff meeting. Clinical Supervisor will review with Executive Director in supervisor meeting on 11/27/23 the outcome. It was addressed that all new patients must have Annual physicals completed within 365 days of admittance and 365 days from the previous annual physical in each consecutive year. Clinical Supervisor will hold weekly clinical and medical meetings to address progress of meeting this expectation to align with DDAP regulations.
Executive Director will monitor weekly progress to ensure POC action steps are being followed to ensure compliance.
Action Steps
1. PTSA clinical supervisor reviewed (11/20/23 )Annual Physicals in a timely manner meeting DDAP regulations.
2. Monthly individual supervisor will address completion of Annual physicals and barriers to meeting regulation.
3. Individual Patient charts will be reviewed during supervision to check compliance.
4. Education and training will be provided in clinical and medical meetings to ensure ongoing compliance.
5. Executive Director will address any barriers with compliance to this regulation in supervision, trainings, and improvement plans. |
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 with all areas of regulation addressed within the regulatory timeframe in three out of five applicable records reviewed.
Patient #2 was admitted on July 13, 2015 and was still active at the time of the inspection. The annual evaluation was due no later than July 13, 2023; however, there is no documentation that one was completed.
Patient #3 was admitted on August 4, 2017 and was still active at the time of the inspection. The annual evaluation was completed on May 5, 2022. The next annual evaluation was due no later than May 5, 2023; however, there is no documentation that one was completed.
Patient #10 was admitted on April 21, 2016 and was still active at the time of the inspection. The annual evaluation was due no later than April 21, 2023; however, it was completed on May 18, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA clinical Supervisor reviewed requirements for completion of Annual Physicals on the 11/20/23 Clinical Staff meeting. Clinical Supervisor will review with Executive Director in supervisor meeting on 11/27/23 the outcome. It was addressed that all new patients must have Annual Evaluations completed within 365 days of admittance and 365 days from the previous annual evaluation in each consecutive year. Clinical Supervisor will hold weekly clinical to address progress of meeting this expectation to align with DDAP regulations.
Executive Director will monitor weekly progress to ensure POC action steps are being followed to ensure compliance.
Action Steps
1. PTSA clinical supervisor reviewed (11/20/23 )Annual Evaluations in a timely manner meeting DDAP regulations.
2. Monthly individual supervisor will address completion of Annual Evaluations and barriers to meeting regulation.
3. Individual Patient charts will be reviewed during supervision to check compliance.
4. Education and training will be provided in clinical meetings to ensure ongoing compliance.
5. Executive Director will address any barriers with compliance to this regulation in supervision, trainings, and improvement plans. |
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 that a comprehensive treatment plan was developed with the client per facility ' s policy and procedure manual within 30 days of admission in four out of four applicable records reviewed.
Client #1 was admitted on February 8, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 8, 2023; however, it was completed on May 1, 2023
Client #4 was admitted on July 31, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 31, 2023; however, there was no documentation that one was completed.
Client #5 was admitted on June 27, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 27, 2023; however, there is no documentation that one was completed.
Client #6 was admitted on August 21, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than September 21, 2023; however, it was completed on October 19, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA clinical Supervisor reviewed requirements for completion of the comprehensive treatment plan on the 11/20/23 Clinical Staff meeting. Clinical Supervisor will review with Executive Director in supervisor meeting on 11/27/23 the outcome. It was addressed that all new patients must have comprehensive treatment plans completed within 30 days of admittance. Clinical Supervisor will hold weekly clinical meetings to address progress of meeting this expectation to align with DDAP regulations.
Executive Director will monitor weekly progress to ensure POC action steps are being followed to ensure compliance.
Action Steps
1. PTSA clinical supervisor reviewed (11/20/23 )comprehensive treatment plan in a timely manner meeting DDAP regulations.
2. Monthly individual supervisor will address completion of comprehensive treatment plans and barriers to meeting regulation.
3. Individual Patient charts will be reviewed during supervision to check compliance.
4. Education and training will be provided in clinical meetings to ensure ongoing compliance.
5. Executive Director will address any barriers with compliance to this regulation in supervision, trainings, and improvement plans.
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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 of eight records reviewed.
Client #1 was admitted on February 8, 2023 and was still active at the time of the inspection. A treatment plan was completed on May 1, 2023 and the next update was due no later than July 1, 2023; however, it was completed on July 17, 2023. The next treatment plan update was due no later than September 17, 2023; however, it was completed on October 18, 2023.
Client #2 was admitted on July 13, 2015 and was still active at the time of the inspection. A treatment plan update was completed on April 15, 2023 and the next update was due no later than June 15, 2023; however, it was completed on August 18, 2023. The next treatment plan update was due no later than October 18, 2023; however, it was completed on October 25, 2023.
Client #3 was admitted on August 4, 2017 and was still active at the time of the inspection. A treatment plan update was completed on April 12, 2023 and the next update was due no later than June 12, 2023; however, it was completed on July 5, 2023. A treatment plan update was completed on July 31, 2023. The next treatment plan update was due no later than October 1, 2023; however, it was completed on October 11, 2023.
Client #8 was admitted on May 22, 2023 and was still active at the time of the inspection. A treatment plan was completed on June 13, 2023 and the next update was due no later than August 13, 2023; however, it was completed on August 20, 2023. The next treatment plan update was due no later than October 20, 2023; however, it was completed on October 25, 2023.
Client #9 was admitted on December 9, 2021 and was still active at the time of the inspection. A treatment plan was completed on May 15, 2023 and the next update was due no later than July 15, 2023; however, it was completed on July 26, 2023. The next treatment plan update was due no later than September 26, 2023; however, it was completed on October 16, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA clinical Supervisor reviewed requirements for completion of the treatment plan updates on the 11/20/23 Clinical Staff meeting. Clinical Supervisor will review with Executive Director in supervisor meeting on 11/27/23 the outcome. It was addressed that all new patients must have treatment plan updates completed within 60 days of the previous plan and every 60 days on an ongoing basis. Clinical Supervisor will hold weekly clinical meetings to address progress of meeting this expectation to align with DDAP regulations.
Executive Director will monitor weekly progress to ensure POC action steps are being followed to ensure compliance.
Action Steps
1. PTSA clinical supervisor reviewed (11/20/23 ) treatment plan updates in a timely manner meeting DDAP regulations.
2. Monthly individual supervisor will address completion of treatment plan updates and barriers to meeting regulation.
3. Individual Patient charts will be reviewed during supervision to check compliance.
4. Education and training will be provided in clinical meetings to ensure ongoing compliance.
5. Executive Director will address any barriers with compliance to this regulation in supervision, trainings, and improvement plans. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in six out of eight applicable records reviewed.
Client #1 was admitted on February 8, 2023 and was still active at the time of the inspection. A comprehensive treatment plan dated May 1, 2023 indicated 2.5 hours of psychotherapy a month. In September and October 2023, the client did not receive any psychotherapy.
Client #2 was admitted on July 13, 2025 and was still active at the time of the inspection. A treatment plan dated August 18, 2023 indicated 2.5 hours of psychotherapy a month. In September and October 2023, the client did not receive any psychotherapy.
Client # 7 was admitted on July 9, 2014 and was discharged on March 3, 2023. A treatment plan dated October 29, 2022 indicated one hour of psychotherapy a month. In February 2023, the client did not receive any psychotherapy.
Client #8 was admitted on May 22, 2023 and was still active at the time of the inspection. The treatment plan dated August 20, 2023 indicated 2.5 hours of psychotherapy a month. In September and October 2023, the client did not receive any psychotherapy.
Client #9 was admitted on December 9, 2021 and was still active at the time of the inspection. The treatment plan dated July 26, 2023 indicated 2.5 hours of psychotherapy a month. In October 2023, the client had one hour of psychotherapy.
Client #10 was admitted on April 21, 2016 and was still active at the time of the inspection. The treatment plan dated July 28, 2023 indicated 2.5 hours of psychotherapy a month. In October 2023, the client did not receive any psychotherapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA Clinical Supervisor reviewed clinical time requirements for counseling hours based on the treatment plan in the 11/20/23 clinical staff meeting. This will be reviewed weekly and monthly moving forward for ongoing compliance. In addressing this regulation, it was reviewed that all patients must be provided counseling hours based on the treatment plan but no less than the regulation based on length of time in treatment. Executive Director will review with supervisors weekly in supervisor meeting to ensure ongoing compliance.
Action step:
1. Clinical Supervisor will review in Individual and Group supervision the ongoing expectations of providing the clinical time outlined in the current treatment plan.
2. Individual Charts will be pulled and reviewed at random in individual and group supervisors to ensure compliance and follow through of POC.
3. Education and training will be ongoing in all supervisors and staff meetings
4. Executive Director will ensure follow through and provide supervision, training, and improvement plans as needed. |
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.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of one applicable record reviewed.
Client #7 was admitted on July 9, 2014 and was discharged on March 3, 2023. A follow up was due no later than May 30, 2023; however, it was completed on July 20, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PTSA clinical Supervisor reviewed requirements for completion of after care follow up on the 11/20/23 Clinical Staff meeting. Clinical Supervisor will review with Executive Director in supervisor meeting on 11/27/23 the outcome. It was addressed that all new patients must have follow up completed within 60 days of discharge. Clinical Supervisor will hold weekly clinical meetings to address progress of meeting this expectation to align with DDAP regulations.
Executive Director will monitor weekly progress to ensure POC action steps are being followed to ensure compliance.
Action Steps
1. PTSA clinical supervisor reviewed (11/20/23 )after care follow up in a timely manner meeting DDAP regulations.
2. Monthly individual supervisor will address completion of aftercare follow ups and barriers to meeting regulation.
3. Individual Patient charts will be reviewed during supervision to check compliance.
4. Education and training will be provided in clinical meetings to ensure ongoing compliance.
5. Executive Director will address any barriers with compliance to this regulation in supervision, trainings, and improvement plans. |