D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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BRIGHTER VISIONS COUNSELING
27 NORTH BROWN STREET SUITE B
LEWISTOWN, PA 17044

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Survey conducted on 11/05/2015

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on November 5, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling 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:	Plan of Correction
709.91(b)(6) LICENSURE Intake and admission 709.91. Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation.
Observations Based on a review of client records, the facility failed to document a psychosocial evaluation in three of seven client records reviewed. The findings include: Seven client records requiring documentation of a psychosocial evaluation were reviewed on 11/5/15. A psychosocial evaluation was not documented in client records # 3, 4, and 7. Client # 3 was admitted into treatment on 9/1/15 and was still active at the time of the inspection. A psychosocial evaluation was not documented in the client's record. Client # 4 was admitted into treatment on 7/20/15 and was still active at the time of the inspection. A psychosocial evaluation was not documented in the client's record. Client # 7 was admitted into treatment on 8/27/15 and was still active at the time of the inspection. A psychosocial evaluation was not documented in the client's record. These findings were reviewed with facility staff during the licensing process.	Plan of Correction This deficiency has been corrected by the Facility Director. Psychosocial Evaluation statements will be included in the comprehensive assessment/treatment plan immediately.
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).
Observations Based on a review of client records, the facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in five of seven client records reviewed. The findings include: Seven client records were reviewed on 11/5/15. Five of seven client records required the documentation of a physician signature on treatment plans. Treatment for these five clients was funded through the Medical Assistance program (CCBH). The facility failed to obtain a physician signature on treatment plans for clients # 3, 4, 5, 6, and 7. Client # 3 was admitted into treatment on 9/1/15 and was still active at the time of the inspection. The client's master treatment plan, dated 9/1/15, was not signed by a physician. Client # 4 was admitted into treatment on 7/20/15 and was still active at the time of the inspection. The client's master treatment plan, dated 7/20/15, was not signed by a physician. In addition, the client's treatment plan update, dated 9/21/15, was not signed by a physician. Client # 5 was admitted into treatment on 2/17/15 and was discharged on 8/14/15. The client's master treatment plan, dated 4/1/15, was not signed by a physician. In addition, the client's treatment plan update, dated 5/31/15, was not signed by a physician. Client # 6 was admitted into treatment on 4/3/15 and was discharged on 8/1/15. The client's master treatment plan, dated 6/2/15, was not signed by a physician. Client # 7 was admitted into treatment on 8/27/15 and was still active at the time of the inspection. The client's master treatment plan, dated 8/27/15, was not signed by a physician. These findings were reviewed with facility staff during the licensing process.	Plan of Correction This deficiency has been corrected by the Facility director. All comprehensive treatment plans for clients funded through the Medical Assistance program (CCBH) are signed by a physician.