INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations against ARS of Lancaster, LP were substantiated. 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 complaint investigation:
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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
One client record was reviewed for counseling services during the on-site inspection. The facility failed to provide the client 2.5 hours of counseling services per month.
Patient # 1 was admitted on 1/8/2016 and was still an active patient at the time of the inspection. The facility failed to provide the patient 2.5 hours of counseling services per month between September 2016 - November 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselors will be trained by the clinical supervisor on 1/9/17 to place stop flags on patients the last two weeks of the month using 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.
Patient #1 has had a compliance goal added to her Treatment Plan. Additionally, the patient's primary counselor has utilized stop flags to ensure that the patient adheres to counseling requirements.
To ensure compliance the clinical supervisor 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 ED 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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