INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13-14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of PA, Susquehanna Center 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 June 6, 2008..
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of administrative materials, the facility failed to designate a Project Director who meets the requirements specified in the Licensing Alert entitled "Project Director Requirements " published May, 2005 or the published definitions in the Pennsylvania Bulletin Volume 26 , Number 5 , Saturday February 3, 1996 and Volume 15 , Number 42 published Saturday October 19 , 1985.
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Plan of Correction
POC #0021
The Facility will designate a Project Director who meets the requirements specified in the Licensing Alert. The Project Director will be the Executive Director of the NHS Susquehanna Center Program and will have the responsibility as outlined in the alert. The Project Director will meet the qualifications and training requirements specified in 28 Pa. Code and will report to the governing body, NHS of PA Board of Directors.
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of administrative and personnel materials, the facility failed to ensure that qualified staff are assigned to clinical counselor positions. Employee # 8 is inappropriately designated as a counselor as this employee does not have a related degree or other qualifying credentials. Employees # 3 and 4 have degrees which are not listed in the Licensing Alert of October 2002, and there is no documentation demonstrating that they are related degrees..
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Plan of Correction
POC #0037
Employee #8 was inappropriately designated as a counselor. This employee does not have the appropriate degree and has not yet attained the CAC. Employee #8 has had the appropriate levels of supervision and experience. The facility director misinterpreted the regulations on qualifications and hence enacted the promotion. Employee # 8's designation has reverted back to counselor assistant as of May 23, 2008. This employee has verbally acknowledged intentions of pursuing certification as an addiction counselor and is in the process of drafting a letter to formalize this intent.
Employee #3 & #4 hold Bachelors of Social Welfare degrees which are not listed in the Licensing Alert of October 2002. The academic transcripts will be sent to the DOH for clarification regarding the appropriateness of this degree and their resumes' will also be included to verify experience. It should be noted, however, that both employee #3 and employee #4 were designated as counselor assistance upon hire and at no time were they designated as counselors.
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative and training materials, the facility failed to document an assessment of staff training needs for the current training year, (2007-2008).
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Plan of Correction
POC #0055
Comprehensive training needs assessments have been completed for all staff for training year 07/08. The facility director will review these individual assessments and create an overall training needs assessment for the facility for training 07/08. This assessment will be completed by 6/13/08 and it will be included in our facility training and staff development manual along with the individual assessments, training plans and evaluations/feedback. Future overall training plans will be completed by the facility director within 60 days of the new licensure year.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative and training materials, the facility failed to document an overall training plan for the current training year, ( 2007-2008).
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Plan of Correction
POC #0057
Following review/development of the training needs assessment; the facility director will develop and document an overall training plan for the 07/08 training year. This will become part of the training and staff development manual by 6/13/08 and future overall training plans will be completed by the facility director within 60 days of the new licensure year.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative and training materials, the facility failed to consistently document training evaluation forms. Evaluation of training forms were missing for some of the training that was attended in employee training records # 1, 2, 3, 4, 5, and 6, representing six of six applicable employee training records reviewed.
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Plan of Correction
POC #0059
All staff will be issued a memo with an attached training evaluation form reviewing the expectations to complete and submit the form to the Facility Director immediately following all trainings. The Facility Director will review the evaluation, record the training hours and file the evaluation and training certificate in the individual staff's training record. Training files will be reviewed quarterly to insure all training evaluations are present. The memo and attached training evaluation form will be issued by the facility director prior to the start of the new licensure year.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative and training materials, the facility failed to document an annual evaluation of the overall training plan of the previous training year.
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Plan of Correction
POC #0061
Prior to the end of the training year the Facility Director will review the Facility training plan, and the individual training plans/evaluations to determine the effectiveness of the plan in meeting the facility training goals and objectives. He will forward a written assessment of the overall training plan of the previous training year to the Project Director for review.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of administrative and training materials, the facility failed to document the required six hours of HIV/AIDS and 4 hours of TB/STD training for the following employees: TB/STD- employee records # 1, 4, 5 and 6; HIV/AIDS- employee records # 1, 4 and 6,(four of seven applicable employee records).
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Plan of Correction
POC #0067
HIV/AIDS and TB/STD training will be provided to the identified employees using the Department approved curriculum. Susquehanna Center's RN will train the identified staff in both curriculums for the minimum required hours within 30 days. To insure future compliance for all new hires the HIV/AIDS and TB/STD Department approved training will be provided to all staff yearly.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of administrative and training materials, the facility failed to document that all staff had been trained in emergency procedures. Documentation that this training occurred was missing for employees # 1, 2, 3, 5 and 6, (5 of 6 applicable employee records reviewed).
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Plan of Correction
POC #P227
There is an existing policy indicating specific duties/responsibilities for staff during an emergency. This policy will be reviewed with all new employees during their first full week of employment and documented in their training record. The Program Director will maintain a tracking face sheet on all new employees that will track all Department and NHS trainings that are required during their initial week of employment. Once completed this will be incorporated into the individual employees training record.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs, the facility failed to use alternate exits during fire drills over the past 12 months. Only the rear exit was used for fire drills during this time period.
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Plan of Correction
POC #P283
Fire drills are conducted as per Section 705.28 (d) (6) with the exception of using alternative exits. Future fire drills will vary the location of the "mock fire", which will insure the use of alternative exits. The Program Director and/or the Office Manager will initiate a monthly fire drill and the placement of the mock fire. The Program Director is ultimately responsible for meeting the requirements of Section 705.28 (d) (6).
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709.22(b) LICENSURE Governing Body
709.22. Governing body.
(b) If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.
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Observations
Based on the review of administrative materials, including the organizational chart, the project has more than one staff member on the governing body. The facility is publicly funded.
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Plan of Correction
POC #0119
The governing body for the project is the NHS of PA Board of Directors which is a subsidiary of the parent organization NHS Human Services Inc. The NHS of PA company is separate and distinct company and none of the sitting board members are employees of NHS of PA. Additional organizational charts and board member rosters for both NHS of PA and NHS Humans Services Inc. have been forwarded to the Department for further clarification.
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709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on the review of administrative materials, the facility failed to identify the qualifications for membership on the board of directors.
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Plan of Correction
POC #0123
NHS of PA Board Members is selected by the Corporate Board, NHS Human Services Inc. The Corporate board has stipulated that all subsidiary boards will be comprised of employees of the parent organization NHS Human Services Inc. and will be appointed by the corporate board for a specified term. Any changes in the NHS of PA board composition will be implemented by the Corporate Board and will be communicated to the Project Director. The changes will then be recorded in the Policies and Procedures of the Project under the direction of the Project Director.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on the review of administrative materials, the project director failed to document the annual update of the manual by dated signature.
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Plan of Correction
POC #0143
The Policy and Procedure manual will be reviewed/updated by the Project Director annually. Once the review is complete the Project Director will sign and date the annual review document.
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709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative records, the facility failed to document that the Project Director and the Board of Directors collaborated in the formulation of project goals and objectives, written reports of project operations and annual performance reports on the progress toward meeting goals and objectives.
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Plan of Correction
POC #0145
The Program Director will develop a quarterly progress report that will describe the projects overall performance on meeting the goals and objectives established for the year. The report will be prepared and forwarded to the Project Director for presentation to the governing board.
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709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of administrative materials, the project director and board of directors did not document annual goals and objectives for the current fiscal year.
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Plan of Correction
POC #0147
The Program Director will develop yearly goals and objectives at the beginning of the year and forward to the Project Director for presentation to the governing board for approval.
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709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on the review of administrative materials, the facility failed to document a performance report summarizing the progress on the annual goals and objectives for the last fiscal year.
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Plan of Correction
POC #0151
The Project Director will compile an annual report on the progress on the annual goals and objectives for the last fiscal year for presentation to the governing board.
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709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on the review of administrative materials, the facility failed to provide documentation of the adoption of the written plan for coordination of treatment services by the board of directors.
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Plan of Correction
POC #0153
The appropriate documentation for the coordination of client treatment and rehabilitation services defining our target population, models of treatment etc. are included in the manual. Following the Project Director's review/update of the manual the required dated sign off of the governing body will be completed.
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709.26(a) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
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Observations
Based on the review of administrative materials, there was no documentation of adoption of project personnel policies and procedures by the board of directors.
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Plan of Correction
POC #0173
The appropriate documentation for the Personnel Management section 709.26 (a) is included in the manual. Following the Project Director's review/update of the manual, the required dated sign off of the governing body approval will be completed.
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709.26(a)(2) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(2) Utilization of volunteers.
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Observations
Based on the review of administrative materials and the facility policy and procedure manual, the facility failed to ensure that there were no conflicting procedures in the manual. In one policy, the manual stated that volunteers would be used in non-essential functions with no treatment services being provided. In a subsequent section of the policy, the manual stated that some volunteers and interns have direct care responsibilities. These are contradictory policy statements.
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Plan of Correction
POC #0177
The Project Director will review/update the policy and procedure manual. We will correct the identified conflict in the Utilization of Volunteers policy.
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709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Based on the review of administrative materials, including the facility policy and procedure manual and facility reports, the facility failed to document the approval of project policies and procedures to implement and coordinate personnel management by the board of directors.
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Plan of Correction
POC #0199
The appropriate policies and procedures are included in the facility manual. Following the review/update by the Project Director the required dated approval sign off of the governing body will be completed.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the agency policy manual, the facility failed to develop a written procedure for the confidentiality of client identity and records that was consistent with state law at 71 P. S. Subsection 1690.108 and state regulations at 4 Pa. Code Subsection 255.5 and 28 Pa. Code Subsection 709.28 as well as the federal regulations at 42 CFR Part 2, Subparts A through E. The facility's 'duty to warn' policy and procedure was not consistent with the federal regulations at 42 CFR Part 2, Subpart E, Subsection 2.63(a)(1) and violated state law and regulations.
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Plan of Correction
POC #0271
As part of the Project Director's review of the Policy and Procedure manual the existing policy on client confidentiality will changed to insure compliance to Federal and State laws and regulations, specifically the facility's duty to warn policy will be removed. All staff will be made aware of these changes immediately by the Program Director and he will conduct training on client confidentiality during the next monthly staff meeting.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to consistently document informed, written consents to release information in client records # 1, 4, 6, 7, 8, 9 and 12. Facility staff did not complete written consents to release information with sufficient detail to rise to the level required for an "informed" consent. The facility failed to list the 'specific' information that would be released on consent to release information forms in client records # 1, 4 and 8. The facility failed to have the client sign a consent to release information form in client record #4. The facility failed to identify the intended recipient of the information on written consent to release information forms in client records # 6, 7 and 12. Seven of ten client records contained written consent to release information forms that were invalid as described above.
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Plan of Correction
POC #0277
The Program Director will conduct a mandatory training regarding confidentiality regulations and the correct procedures for completing release of information forms prior to the start of the new licensure year. Future chart audits will focus on this issue.
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709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to consistently document informed written consents to release information which complied with 4 Pa. Code subsection 255.5(b) relating to specific information to be disclosed. The information listed on the consent to release information forms in client records # 2, 4 and 5 exceeded the limitations imposed for released to health and hospital plans, insurance companies, criminal justice entities and government officials. The facility failed to list the 'specific' information that would be released on the written consent to release information forms in client records # 1 and 8. Information was released to a government agency without written consent in client record # 9. The client record sample was ten records.
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Plan of Correction
POC #279
The Program Director will conduct a mandatory training regarding confidentiality regulations and the correct procedures for completing release of information forms prior to the start of the new licensure year. Future chart audits will focus on this issue.
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative records, the facility failed to maintain a record keeping system that allowed for efficient retrieval of information. Specifically, the administrative materials requested were unavailable during the inspection (staff training plan documentation, documentation of board approval of documents and policy and procedures and goals and objectives).
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Plan of Correction
POC #0313
The facility will develop a record keeping and retrieval system that will insure that administrative materials are readily accessible during inspections. The Program Director with the assistance of the Project Director and Office Manager will develop the record keeping and retrieval system. The Program Director is ultimately responsible for the implementation of this system.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to consistently document complete personal histories. Family dynamics and interrelationships were incomplete in client records # 1, 2, 3, 4 5, 6, 7, 8, 9 and 11. Employment histories were missing complete information (employers, dates, jobs held) in client records # 2, 4, 5 and 7. Sexual histories did not address sexual orientation in client records #1, 2, 3, 4, 5, 6, 7, 8, 9 and 11. Ten client records were included in this sample.
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Plan of Correction
POC #1865
The Program Director will conduct mandatory training regarding the Intake and Admissions procedures prior to the start of the new licensure year. The training will emphasize the importance a complete personal/family history. Future chart audits will focus on this issue.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to consistently document complete psychosocial evaluations. In client record # 1 the evaluation portion of the record was not completed. Coping mechanisms were missed in client records # 1, 2, 3, 5, 6, 8 and 12. Strengths and assets were either missed or documented only from the client's viewpoint in client records # 1, 2, 5 and 12. the client's attitude toward treatment was missed in client records # 1, 2 and 3. Clinical impressions failed to provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in client records # 1, 2, 3, 4, 8 and 12. The clinician's impressions were written from the clients' viewpoint or did not include the specific recommendations for treatment based on the analysis of the collected historical information by the clinician in all ten client records. The sample consisted of ten records.
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Plan of Correction
POC #1871
The Program Director will conduct mandatory training prior to the start of the new licensure year regarding the Intake and Admissions procedures. The training will emphasize the importance of a thorough psychosocial evaluation to develop a composite picture of the individual in relationship to the collected historical information to identify possible relationships, conditions and causes leading to the client's current situation. Future chart audits will focus on this issue.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to consistently document preliminary treatment plans. Preliminary treatment plans were late or missing in client records # 1, 2, 3, 4, 9 and 12. The overall client record sample was 11 records.
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Plan of Correction
POC #1873
The Program Director will conduct mandatory training prior to the start of the new licensure year regarding the Intake and Admission procedures. The training will emphasize the importance of the preliminary treatment and rehabilitation plan and the adherence to NHS timelines regarding its completion. Future chart audits will focus on this issue.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to consistently document proposed types of support services on the treatment plans. No support services were documented in client records # 1, 6, 7, 9 and 12, or 5 of 8 applicable client records reviewed. The overall client record sample was 11 records.
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Plan of Correction
POC #1881
The Program Director will conduct mandatory training prior to the start of the new licensure year regarding the importance of documenting proposed support services as part of the client's treatment and rehabilitation plan. Future chart audits will focus on this issue.
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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 consistently document treatment plan updates which addressed progress in relationship to the stated goals of the comprehensive treatment plan within the 60 day time frame. Treatment plan updates are required every sixty days and were missed in client records # 4 and 12 . The update was late in client record # 9. The content of the update in client record # 9 did not address the stated goals. The client record sample consisted of 11 records.
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Plan of Correction
POC #1883
The Program Director will conduct mandatory training prior to the start of the new licensure year regarding the importance of reviewing and updating treatment plans at a minimum every sixty days. Future chart audits will focus on this issue.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to consistently document complete records of service. The record of service was not current in client record # 12. The records of service in client records # 1, 2, 3, 9, 10 and 12 did not contain information specifying the duration of service. The record sample consisted of eleven client records.
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Plan of Correction
POC #1895
The Program Director will conduct mandatory training prior to the start of the new licensure year regarding the completion of the client record of service that is separate from the progress note. The training will emphasize the need to record the client's involvement with the project including the date of service, type of service, provider of service, and duration of service. Future chart audits will focus on this issue.
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709.93(a)(7) 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:
(7) Client-related correspondence.
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Observations
Based on a review of client records, the facility failed to consistently document client related correspondence. The facility failed to maintain client related correspondence, as well as verbal communications with other persons or agencies, on file in accordance with this regulation and 4 Pa. Code subsection 255.5(a)(10).
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Plan of Correction
POC #1903
The Program Director will conduct mandatory training prior to the start of the new licensure year regarding the need to document client related correspondence and other verbal communications with other persons or agencies on file in accordance with 4 Pa. Code subsections 255.5(a)(10). Future chart audits will focus on this issue.
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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 administrative records, the facility failed to document a signed provider agreement with the Department of Public Welfare identifying the Medical Director as the physician of record with the Department of Public Welfare in accordance with this regulation and the requirements at 55 Pa. Code Part III ( relating to the medical assistance manual).
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Plan of Correction
POC #1931
The Project Director will procure a current signed provider agreement with the Department of Public Welfare. A copy of our Doctor's license was faxed and mailed to the DPW on 6/9/08.
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