INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Beal Counseling and Consulting 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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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Ten client records were reviewed on October 27, 2016, six of which required documentation of case consultations. The facility failed to document a case consultation in three of the six records requiring case consultations. Specifically, in client records #6, #8 and #10.Client #6 was admitted on 2/2/16 and was discharged on 4/28/16.Client #8 was admitted on 10/16/15 and was discharged on 11/20/15. Client #10 was admitted on 6/22/16 and was discharged on 9/15/16. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project director will review and train all staff to complete Case Consultations prior to discharge (for treatment episodes of less than 90 days specifically). The general Case Consultation policy will also be reviewed. This occurred on 11/11/16. |
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
Ten client records were reviewed on October 27, 2016, three of which required a physician's signature on treatment plans, treatment plan updates and psychosocial evaluations. The facility failed to obtain the physician's signature on treatment plans, treatment plan updates and psychosocial evaluations in three of three records. Specifically, client records #1, #2 and #4. Client #1 was admitted on 5/26/16 and was still an active client at the time of the inspection. Client #2 was admitted 8/25/16, and was still an active client at the time of the inspection. Client #4 was admitted on 7/13/16, and was still an active client at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has submitted a request for a waiver of this regulation. A request was submitted to Secretary Tennis 11/09/2016 and also to Secretary Dallas on 11/10/2016. |