INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and Methadone/Buprenorphine monitoring inspection conducted on November 14-15, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, ARS of Lancaster, LP 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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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records conducted during the onsite inspection, the facility failed to ensure that it provided sufficient psychotherapy services in one of eight narcotic treatment program patient records reviewed.
Patient# 5 was admitted for narcotic treatment on 11/09/2016, and was discharged on 10/23/2017. The patient received zero hours of psychotherapy in the months of May, June and July of the year 2017, and only one hour of psychotherapy in the month of August of the year 2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Counselors will utilize stop flags in the Methasoft system to ensure all patients who are noncompliant with counseling hours meet with their counselor prior to medicating and complete treatment requirements for the month. The patient's primary counselor will document all missed counseling appointments in the patient record.
To ensure compliance the clinical supervisor (CS) will review with each counselor monthly that each patient received the minimum 2.5 hours of psychotherapy, with at least one hour of individual counseling per month for the first 2 years of treatment. The Executive Director will meet with the CS on a monthly basis to ensure compliance is achieved and to address any concerns on an ongoing basis.
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