INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 22, 2014 to October 23, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mid-Atlantic Rehabilitation Services - A.T.P. 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:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" completed by the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Reports" for the one facility within the Project was reviewed. The "Staffing Requirements Facility Summary Report" completed by the facility on September 29, 2014 listed a total of 19 counselors, 1 counselor assistant, and 1 staff member identified as the clinical supervisor. However, the staff member identified as the clinical supervisor is part-time.
The total number of drug and alcohol counseling hours per week provided by the Project equated to 9.325 FTE counselors within the Project; therefore, the project was required to have at least 1 full-time clinical supervisor. The "Staffing Requirements Facility Summary Report" did not list a full-time clinical supervisor and only identified 1 part-time clinical supervisor for the Project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agencies board of directors will submit an exception request regarding the full time clinical directors position. If the exception is not granted the agency will reduce the FTE number to 7.5 FTE's which is sufficient to maintain our licensed capacity and/or develop a plan to obtain a Full Time clinical supervisor. |
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, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual) in three of three client records reviewed.
The findings include:
Three records requiring documentation of a physician's signature on client treatment plans were reviewed from October 22, 2014 to October 23, 2014. The facility failed to ensure a physician signed the individual treatment and rehabilitation plans and treatment plan updates in client records # 8, 11, and 16.
Client # 8 was admitted June 26, 2014 and was still an active client as of 10/23/14. The individual treatment and rehabilitation plan was completed July 7, 2014 and treatment plan update was completed September 8, 2014. The facility was required to ensure a physician sign the individual treatment and rehabilitation plan and treatment plan update. However, the facility failed to ensure a physician signed the individual treatment and rehabilitation plan and treatment plan update as of October 23, 2014.
Client # 11 was admitted December 13, 2013 and discharged April 3, 2014. The individual treatment and rehabilitation plan was completed January 16, 2014 and treatment plan update was completed March 13, 2014. The facility was required to ensure a physician sign the individual treatment and rehabilitation plan and treatment plan update. However, the facility failed to ensure a physician signed the individual treatment and rehabilitation plan and treatment plan update as of October 23, 2014.
Client # 16 was admitted January 13, 2014 and discharged May 30, 2014. The individual treatment and rehabilitation plan was completed January 29, 2014 and treatment plan update was completed March 26, 2014. The facility was required to ensure a physician sign the individual treatment and rehabilitation plan and treatment plan update. However, the facility failed to ensure a physician signed the individual treatment and rehabilitation plan and treatment plan update as of October 23, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Meeting will be conducted with the medical director by the Project Director by 12/1/2014 to review the regulatory requirements and review the correct location to sign treatment plans and the need to sign each treatment plan separately and individually instead of signing the preliminary plan on multiple dates. |