INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Arc Manor - Leechburg Satellite 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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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 a treatment and rehabilitation plan update at least every 60 days in two of six client records reviewed.
The findings include:
Six client records requiring documentation of a treatment plan update were reviewed on March 23, 2016. The facility failed to document a treatment plan update at least every 60 days in client records # 4 and 5.
Client # 4 was admitted into treatment on 8/18/15 and was discharged on 12/2/15. A comprehensive treatment plan was completed for the client on 8/31/15. The subsequent treatment plan update for the client was completed on 11/20/15.
Client # 5 was admitted into treatment on 9/4/15 and was discharged on 2/11/16. A comprehensive treatment plan was completed for the client on 10/15/15. The subsequent treatment plan update for the client was completed on 2/8/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director is responsible for the supervision of the therapist involved with this citation. As both of these findings are related to the file management of the same therapist, this therapist will receive a disciplinary action regarding compliance with the agency standards on outpatient treatment planning. This disciplinary action will be reviewed by the Executive Director with the staff person during supervision on April 19, 2016. In addition, this therapist was required to attend an in house "Treatment Planning" training on March 24, 2016 as timeliness and quality of treatment plans had already been identified by the agency as an area of training need prior to the licensing visit. Corrective action moving forward will be that therapist opens the current treatment plan for the client at every session to determine appropriateness of the current goals and objectives as well as the need to update the plan. Therapist will also keep a calendar in the Electronic Health Record's Scheduler that notes the due date of all treatment plans for active clients. Monthly supervision with the Executive Director will address the disciplinary action and corrective action planning for 6 months to ensure that the problems have been resolved. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete client record on an individual which included information relative to the client's involvement with the project was documented in two of six client records reviewed.
The findings include:
Six client records were reviewed for documentation of a complete client record on March 23, 2016. The facility failed to document a discharge summary in client records # 1 and 5.
Client # 1 was admitted into treatment on 11/12/15 and was discharged on 2/3/16. A discharge summary was not documented in the client's record.
Client # 5 was admitted into treatment on 9/4/15 and was discharged on 2/11/16. A discharge summary was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For the files identified, the same therapist was involved in both cases. This therapist was told to add a discharge summary into these client records so that the files were complete. In addition, since client discharge documentation has already been addressed with this therapist in supervision, a formal disciplinary action will be written and addressed with this staff person in individual supervision on 4/19/2016. The corrective action for this disciplinary action will be that the therapist reviews the agency's discharge protocol and checklist and follows the agency standard that all discharge documentation is completed within 7 days from the date of discharge. In addition, therapist is given a weekly caseload list in Clinical Staffing and will highlight any clients who have been discharged and then turn the list into treatment supervisor weekly. The Treatment Supervisor will ensure that the work is being completed in a timely manner. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in one of six client records reviewed.
The findings include:
Six client records were reviewed on March 23, 2016. Two of the six records required the documentation of a physician signature on treatment plans, as treatment was funded through the Medical Assistance program. The facility failed to obtain a physician signature on a treatment plan for client # 4 .
Client # 4 was admitted into treatment on 8/18/15 and was discharged on 12/2/15. The client's treatment was funded through the Medical Assistance program. A treatment plan update, completed for the client on 11/20/15, was not signed by a physician.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In response to this issue, the Medical Director was contacted by the Executive Director following the licensing visit and was reminded to log into the EHR and review and sign all documentation in a timely manner. The process for physician signatures on EHR documents is that they are reviewed at least weekly to maintain timely signatures on all documents. The issue in both files identified was not actually with the physician, but with the treatment supervisor. The treatment supervisor had not yet reviewed and signed the documents in order to send them on to the physician for final signature. The Correction for this issue is that, during the April 26, 2016 Manager's meeting, the Executive Director will remind all treatment supervisors of the need to log into their alerts daily to sign off on any documentation. In addition, the Executive Director will have access to and be responsible for monitoring treatment supervisor and Medical Director alerts weekly through the Electronic Health Record. If the Executive Director determines that any party is falling behind in signing alerts/documentation (more than 10 documents unsigned at the end of each week) then a corrective action plan will be built with that individual for how to better manage this task and this corrective action will be documented in supervision notes. |