Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form, the facility failed to ensure that the staff to client ratio remained at or under one full time equivalent (FTE) counselor for every ten clients. The findings include:On June 21, 2012, the SRFSR form completed by the facility was reviewed. The facility was required to have one FTE counselor for every ten clients. The SRFSR form listed one clinical supervisor and three counselors as the clinical staff. The facility listed three counselors providing a combined total of twelve clinical hours per week at the facility and there were six active clients in the partial hospitalization activity. Based on this information, the client to counselor ratio was 19:1.\ The findings were confirmed during an interview with the Vice President/Chief Operations Officer on June 21, 2012 at approximately 2:45 P.M.This is a repeat citation. The facility was cited on January 12, 2012 for noncompliance with this standard.
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Plan of Correction
A portion of one additional counselor's time will be assigned in order to bring the ratio within guidelines.
The clinical director and the chief operating officer are charged with implementation, review and ratio monitoring.
Corrective action will be fully implemented by August 10. A pending staff resignation will necessitate a reallocation of each staff member's time following the counselor's departure. |
Observations
Based on a review of client records, the facility failed to comply with 55 Pa. Code Part III (relating to the Medical Assistance Manual) in five of five client records.The findings include:The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (i) - (ii) specifies that "within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. ... Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician."On June 21, 2012, five client records requiring documentation of a physician's signature on treatment and rehabilitation plans and four client records requiring documentation of a physician's signature on treatment and rehabilitation plan updates were reviewed.A physician did not sign the individual treatment and rehabilitation plan in five of five records reviewed, specifically, client records # 1, 2, 3, 4, and 5. Also, a physician did not sign the individual treatment and rehabilitation plan update in four of four records reviewed, specifically, client records # 1, 3, 4 and 5. Client # 1 was admitted April 3, 2012. A physician was required to sign the individual treatment and rehabilitation plan and the treatment plan update. The individual treatment and rehabilitation plan was completed April 16, 2012 and the treatment plan update was completed June 15, 2012. However, the individual treatment and rehabilitation plan and the treatment plan update did not include documentation of a physician's signature as of June 21, 2012. Client # 2 was admitted April 19, 2012. A physician was required to sign the individual treatment and rehabilitation plan. The individual treatment and rehabilitation plan was completed May 9, 2012. However, the individual treatment and rehabilitation plan did not include documentation of a physician's signature as of June 21, 2012. Client # 3 was admitted April 10, 2012. A physician was required to sign the individual treatment and rehabilitation plan and the treatment plan update. The individual treatment and rehabilitation plan was completed April 10, 2012 and the treatment plan update was completed June 14, 2012. However, the individual treatment and rehabilitation plan and the treatment plan update did not include documentation of a physician's signature as of June 21, 2012. Client # 4 was admitted February 14, 2012. A physician was required to sign the individual treatment and rehabilitation plan and the treatment plan update. The individual treatment and rehabilitation plan was completed March 16, 2012 and the treatment plan update was completed May 16, 2012. However, the individual treatment and rehabilitation plan and the treatment plan update did not include documentation of a physician's signature as of June 21, 2012. Client # 5 was admitted March 28, 2012. A physician was required to sign the individual treatment and rehabilitation plan and the treatment plan update. The individual treatment and rehabilitation plan was completed March 28, 2012 and the treatment plan update was completed May 28, 2012. However, the individual treatment and rehabilitation plan and the treatment plan update did not include documentation of a physician's signature as of June 21, 2012. The findings were confirmed during an interview with the Vice President/Chief Operations Officer on June 21, 2012 at approximately 12:30 P.M.This is a repeat citation. The facility was cited on January 12, 2012 for noncompliance with this standard.
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Plan of Correction
- The facility will enter into a Qualified Service Organization Agreement (QSOA) with the physician and fax treatment plans to him weekly for review and signature, emphasizing the timeliness of that signature. Originals of the treatment plans will be kept on file in the office. The signed fax copy of the document will be retrieved bi weekly from the physician and placed in the client file next to the original document
Responsible: Vice President or designate is responsible for the carrying out of this task and also monitoring and communicating with the physician.
Date: By October 25, 2012
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