INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1-2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, Inc., 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 and a plan of correction is due on March 1, 2010.
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Plan of Correction
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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 and treatment plan updates as per 55 Pa. Code Part III in one of one client records.
The findings include:
Thirteen outpatient client records were reviewed on February 2, 2010. One of the clients reviewed was being funded by medical assistance and therefore all treatment plans and updates for that client must be reviewed by a physician. As of February 2, 2010, the facility did not document a physician signature on the treatment plan for client #3.
Client # 3 was admitted on January 12, 2010 and the comprehensive treatment plan was developed on January 19, 2010.
It was confirmed with the project director and facility director that the physician provides services to the program twice per week.
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Plan of Correction
The Project Director, Program Director and Clinical Supervisor provided the counseling staff with instruction and training on the requirement for a physician signature on treatment plans and treatment plan updates as per 55 Pa. Code Part III. This requirement will be reviewed additionally during annual refresher training. The Clincal Supervisor shall review all treatment plans and treatment plan updates upon their completion. The Clinical Supervisor shall ensure that all clients being funded by medical assistance will have their treatment plans and treatment plan updates signed by a physician prior to their completion.The Clinical Supervisor shall ensure that the counseling staff and physician sign off on the treatment plans and treatment plan updates prior to their review and subsequent signature. Compliance with 55 Pa. Code Part III will also be checked during the Clinical Supervior's documented monthly chart reviews. This plan of correction is currently effective and in place. |