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 29, 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-III, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of fourteen employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 14. Employee # 14 was hired as a counselor on January 25, 2021 and was still in this position at the time of the inspection. Based on a review of employee # 14's personal record and resume, there was no documentation of at least two years of clinical experience with an associate degree. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, upon reviewing a candidate's resume and application, prior to the interview and hiring process, the Executive Director will consult with the Regional Director and HR to ensure that qualifications are met for the specific position being offered.
Employee #14 will remain a counselor assistant until January 25, 2023. She will continue to receive supervision twice a month at minimum. She will continue to have group supervision weekly. Documentation and caseload will be reviewed weekly with Employee #14. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.Client # 8 was admitted on November 30, 2021 and was discharged on August 1, 2022. An informed and voluntary consent from the client for the disclosure of information dated July 1, 2022 to a treatment facility released information without a dated signature of the client. The client was transferred to another facility and transfer information was sent however, the consent to release form had "verbal consent due to being inpatient" instead of a signature. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Once consent is obtained due to patient being admitted into a higher level of care and being unable to sign at our facility, counselor will fax over our ROI for patient to sign for our documentation. If other facility is unresponsive, counselor will notify Executive Director to coordinate that the documentation process has been completed. This will be monitored through monthly supervision effective 10/19/2022 and chart audits conducted by Clinical Supervisors and Executive Director. |
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 four of eight 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 # 2 was admitted on December 9, 2021 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 month of :August 9- September 8- .95 minutesPatient # 5 was admitted on October 26, 2021 and was discharged July 22, 2022. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of :June 26- July 25- .95 minutesMay 26- June 25- 0February 26- March 25- .95 minutesDecember 26- January 25- .49 minutesNovember 26- December 35- .91 minutesNo shows documented March 18, June 17, July 1Patient # 7 was admitted on October 5, 2021 and was discharged November 5, 2021. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of :October 5- November 5- 0Patient # 8 was admitted on November 30, 2021 and was discharged August 1, 2022. A review of progress notes indicates the patient did not receive 2.5 hours of psychotherapy a month for the months of :June 30- July 29- 0May 30- June 29- 0February 28- March 29- 0January 30- February 28- 0December 30- January 29- 0November 30- December 29- 0These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Through our Electronic Health Record we will place alerts on the patients to notify them of their counseling sessions each month. Treatment Teams will be conducted with staff , patient and Clinical Supervisor to evaluate barriers in making clinical time. If barriers continue, the Executive Director will be involved in the Treatment Teams. Counseling sessions are being offered at various times to ensure all patients are given the opportunity and flexibility to attend their sessions. The Clinical Supervisors will continue to monitor through monthly supervision effective 10/19/2022 and chart audits that clinical time is being met. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on one 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 # 7 was admitted on October 5, 2021 and was discharged November 5, 2021. Patient # 7 was transferred to another facility on November 5, 2021. There was no documentation of admission date, medical and psychosocial summaries, exception requests, and current status of the patient when transferring the patient. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 21, 2021 annual licenising inspection.
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Plan of Correction
Executive Director and Clinical Supervisors will educate staff during individual and group supervisions the process of completing transfer paperwork. Staff are instructed to obtain fax confirmation that the documentation was sent successfully to the transferring facility and staff will upload all documentation into the EHR. Clinical Supervisors and ED will continue to monitor monthly during supervision effective on 10/19/2022 and through monthly chart audits including discharge charts. |