INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on July 14, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pinnacle Treatment Centers PA-III, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of Unusual Incident Reports that were submitted to the Department since May 2022 and an interview with the facility director, the facility failed to inform the Department of an unusual incident within the required 48 hours.
It was discovered that the facility was notified on May 31, 2022 that a patient passed away on May 28, 2022. The facility did not submit a written unusual incident report to Department within the regulatory 48 hours.
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Plan of Correction
The Executive Director will follow unusual incident policy/procedure by completing internal sentinel report and submitting an Unusual Incident Report per regulation on the DDAP online portal. The Executive Director will verify that the report was received by printing the verification report received through email. The Executive Director will conduct monthly checks including the internal Critical Incident Tracker Form to monitor that all unusual incidents are being reported through the DDAP online portal. |