INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on January 20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Counseling Services was found to be not 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(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Seven client records were reviewed on January 20, 2017. The facility failed to document the frequency of treatment and rehabilitation services on the comprehensive treatment plan, in client records # 5, 6, and 7.
Client # 5 was admitted into treatment on 1/20/16 and was discharged on 6/17/16. The comprehensive treatment plan documented in the client's record, completed on 2/1/16, did not specify the frequency of individual therapy.
Client # 6 was admitted into treatment on 8/16/16 and was discharged on 10/12/16. The comprehensive treatment plan documented in the client's record, completed on 8/26/16, did not specify the frequency of group therapy and support group meetings.
Client # 7 was admitted into treatment on 5/25/16 and was discharged on 7/20/16. The comprehensive treatment plan documented in the client's record, completed on 5/25/16, did not specify the frequency of group therapy and support group meetings.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 1/27/17 all Addiction Counselors were given a refresher training on including the type and frequency of treatment and rehabilitation services on the comprehensive treatment plan. This will be routinely checked by the Team Leader via monthly chart reviews. |
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
Seven client records were reviewed on January 20, 2017. The facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in client records # 2 and 5. Treatment for these clients was funded through the Medical Assistance Program (CCBH).
Client # 2 was admitted into treatment on 11/18/16 and was still active in treatment. The comprehensive treatment plan documented in the client's record, completed on 11/18/16, was not signed by a physician.
Client # 5 was admitted into treatment on 1/20/16 and was discharged on 6/17/16. The comprehensive treatment plan documented in the client's record, completed on 2/1/16, was not signed by a physician.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 2/24/17 all Addiction Counselors and Physicians were trained on the Department of Public Welfare 55 PA Code Part III that a physician's signature is needed on the comprehensive treatment plan. This will be monitored by the Team Leader via monthly chart reviews and added to the Quarterly Quality Chart review process.
The Senior Director of Outpatient is responsible for the implementation of this Plan of Correction.
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