Observations
Based on the review of client records and an interview with the Facility Director, the facility failed to ensure compliance with 55 Pa. Code Part III (relating to the Medical Assistance Manual).
The finding includes:
The annual onsite licensing renewal inspection was conducted on May 8- 9, 2013. During the course of the inspection six client records were reviewed. Three of these records were funded by MA/ Healthchoices monies and were required to be in full compliance with 55 Pa. Code Part III requirements. These requirements include having a physician sign off on the preliminary treatment plans, Master Treatment Plans and treatment plan updates. The preliminary treatment plans and treatment plan updates were not signed by the physician in three of three applicable records.
Client record # 1 - This client was admitted on 2/22/12 and discharged on 3/4/13. The preliminary treatment plan dated 2/22/12 was not signed by the physician. Treatment plan updates dated 3/7/12 were not signed by the physician.
Client record # 4- This client was admitted on 4/26/13 and last treated on 4/26/13. The preliminary treatment plan dated 4/26/13 was not signed by the physician.
Client record # 5- This client was admitted on 8/15/12 and was last treated on 5/3/13. The preliminary treatment plan dated 1/29/13 was not signed by the physician. Treatment plan updates dated 11/16/12, 1/15/13, 3/16/13 and 4/29/13 were not signed by the physician.
The finding was confirmed with the Facility Director on 5/8/13.
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Plan of Correction
1.Revise Initial Treatment Plan and Treatment Plan Update documents by adding physician signature line. Responsible Person: Director Target Date: 5/15/13.
2. Meet with Medical Director to review revised requirements and operational protocol. Responsible Person: Director. Target Date: 5/17/13.
3. In-sevvice staff on revised protocol and requirements. Responsible Person: Director Target Date: 5/20/13.
4.Revise Treatment Plan Policy to reflect Revised Requirements. Responsible Person: Director Target date: 5/24/13.
5. Monitor compliance via review of new cases and treatment plan review. Responsible Persons: Clinical Supervisors. Tatget Date: 6/3/13.
Date of anticipated standard compliance: 6/3/13.
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