INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services - Reading Psychiatric 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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709.94(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 and an interview with quality improvement staff, the facility failed to ensure that the physician and client signed the treatment plan and treatment plan updates, as required by 55 PA. Code Part III relating to Medical Assistance Manual
The finding includes:
Sixteen client records were reviewed on February 20, 2013. During the review of client records it was observed that the client and physician were not signing the treatment plans and treatment plan updates. The facility had an addendum for signatures that documented the client and physician signatures. This did not comply with 55 PA. Code Part III (relating to Medical Assistance Manual) as it relates to required documentation on treatment plans and treatment plan updates.
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Plan of Correction
The Project Director and/or Facility Director will oversee that the electronic record system is modified to allow client and psychiatry signatures to be documented on the electronic treatment plan. The Vice President of Quality Improvement and/or Director of Quality Improvement will ensure that client signatures and psychiatry signatures are documented on the treatment plans via random chart audits. |