Observations
Based on a review of client records, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual) in two of two client records reviewed.
The findings include:
Two records requiring documentation of a physician's signature on client treatment plans were reviewed on September 11, 2014. The facility failed to ensure a physician signed the individual treatment and rehabilitation plans and/or treatment plan updates in client records # 1 and 3.
Client # 1 was admitted June 23, 2014 and was still an active client as of 9/11/14. The individual treatment and rehabilitation plan was completed July 8, 2014 and treatment plan update was completed September 5, 2014. The facility was required to ensure a physician sign the individual treatment and rehabilitation plan and treatment plan update. However, the facility failed to ensure a physician signed the individual treatment and rehabilitation plan and treatment plan update as of September 11, 2014.
Client # 3 was admitted February 20, 2014 and was still an active client as of 9/11/14. Treatment plan updates were completed July 7, 2014 and September 5, 2014. The facility was required to ensure a physician sign the treatment plan updates. However, the facility failed to ensure a physician signed the treatment plan update completed on September 5, 2014 as of September 11, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to keep in compliance with 55 Pa. Code Part III the E. Stroudsburg PATH Center Drug & Alcohol Counselor will fax all required paperwork on clients to the Turbotville Facility Director in a timely manner so as to get the required physician signature. The Turbotville Facility Director will be in charge of obtaining the actual signature from the physician and then in a timely manner the paperwork with the original physician's signature will be sent back to the E. Stroudsburg Drug & Alcohol Counselor who will then replace the paperwork with the physician's signature back into the client's chart. Follow up communication will be done between the E. Stroudsburg Drug & Alcohol Counselor and the Turbotville Facility Director regarding the sending of documents/paperwork in both directions (to and from). The staff involved in monitoring this POC will be the Turbotville Facility Director, E. Stroudsburg Facility Director, & the E. Stroudsburg Drug & Alcohol Counselor. The individual treatment plan and/or treatment plan updates for client records # 1 and 2 are now signed by the physician.
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