INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13-14, 2016 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Seventeen client records were reviewed on October 13-14, 2016. The facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure in client record # 11.
Client # 11 was admitted into treatment on 12/1/15 and was discharged on 5/11/16. A consent to release information to the client's treatment funding source, signed and dated on 3/14/16, did not document the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client record 11 will be reviewed and if client remains in service purpose will be identified and initialed by client and counselor. An in-service reviewing compliant completion of consent to release information forms will be conducted by director and clinical supervisor by 12/23/16. An audit of 10% of active records will be conducted by Quality Improvement team monthly to monitor compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Seventeen client records were reviewed on October 13-14, 2016. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 2, 5, 8, 10, 11, and 14.
Client # 1 was admitted into treatment on 2/6/15 and was active in treatment. The client's record documented that a treatment plan update was completed on 5/9/16. A subsequent treatment plan update documented in the record was completed on 8/1/16.
Client # 2 was admitted into treatment on 3/2/16 and was active in treatment. The master treatment plan documented in the client's record was completed on 3/31/16. A subsequent treatment plan update documented in the record was completed on 8/3/16. The next treatment plan update for the client was due to be completed by 10/3/16 and this was not documented in the client's record.
Client # 5 was admitted into treatment on 7/14/16 and was active in treatment. The master treatment plan documented in the client's record was completed on 8/4/16. A treatment plan update was due to be completed for the client by 10/4/16 and this was not documented in the client's record.
Client # 8 was admitted into treatment on 2/2/16 and was discharged on 7/1/16. The master treatment plan documented in the client's record was completed by 2/13/16. A subsequent treatment plan documented in the record was completed on 4/26/16. The next treatment plan update for the client was due to be completed by 6/26/16 and this was not documented in the client's record.
Client # 10 was admitted into treatment on 4/21/16 and was discharged on 9/13/16. The master treatment plan documented in the client's record was completed on 5/12/16. A subsequent treatment plan update documented in the record was completed on 8/18/16.
Client # 11 was admitted into treatment on 12/1/15 and was discharged on 5/11/16. The master treatment plan documented in the client's record was completed on 12/8/15. A subsequent treatment plan update documented in the record was completed on 4/5/16.
Client # 14 was admitted into treatment on 1/22/16 and was discharged on 8/18/16. The master treatment plan documented in the client's record was completed on 1/29/16. A subsequent treatment plan update documented in the record was completed on 6/16/16.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Retraining through an in-service with agency staff will be conducted by clinical director and Facility Director on policies and procedures related to completion of treatment plan updates, and retraining on use of treatment plan module in the EHR that was implemented in 2/2016. A 10% audit of active charts by the quality assurance team will be conducted monthly to ensure compliance with policies and procedures. |
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
Seventeen client records were reviewed on October 13-14, 2016. The facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in client records # 3, 4, and 12. Treatment for these clients was funded through the Medical Assistance program.
Client # 3 was admitted into treatment on 4/19/16 and was active in treatment. The master treatment plan documented in the client's record, completed on 5/18/16, was not signed by a physician.
Client # 4 was admitted into treatment on 5/31/16 and was active in treatment. The master treatment plan documented in the client's record, completed on 6/16/16, was not signed by a physician. Additionally, a treatment plan update documented in the client's record, completed on 10/12/16, was not signed by a physician.
Client # 12 was admitted into treatment on 1/7/16 and was discharged on 6/3/16. A treatment plan update documented in the client's record, completed on 4/18/16, was not signed by a physician.
This is a repeat citation, as the facility was cited for non-compliance of this standard in the previous licensing inspection, which was completed on 10/5/15.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A discussion with Medical Director regarding the signature process on all treatment plans will be conducted by 12/23/16 by the clinical director and facility director with the medical director. Monitoring for monthly quality assurance meetings will include a review of treatment plans physician was to sign. Medical Director will be asked to sign client #3, 4, and 12 treatment plans. |