INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services York 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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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in two of four client record.
The findings include:
Ten client records were reviewed on February 25, 2013. Per the facility policy, the counselor and client will complete an aftercare plan prior to discharge for successful completions. An aftercare plan was required in four client records. The facility did not document an aftercare plan in client records #6 and 8.
In client record # 6, the client was admitted on June 15, 2012 and was discharged on January 7, 2013. There was no documentation of an aftercare plan.
In client record #8, the client was admitted on September 19, 2012 and was discharged on January 11, 2013. There was no documentation of an aftercare plan.
This was discussed and confirmed with facility staff on February 25, 2013.
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Plan of Correction
The Facility Director and/or Clinical Supervisor will meet with all staff during staff meeting and review the procedure for completing the aftercare plan with the client prior to discharge for successful completions. The office administrator will complete a weekly review of discharged charts to ensure completion of the aftercare plans. |
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.
The finding includes:
Ten client records were reviewed on February 25, 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 as it is required that the treatment plans and updates are signed.
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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. |