INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28-May 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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 and a plan of correction is due on May 30, 2008.
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Plan of Correction
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709.83(a)(9) LICENSURE Client records
709.83. 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) Progress notes.
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Observations
Based on a review of four client records, the facility failed to document complete progress notes in two client records, # 13 and 14. Progress notes for group counseling failed to include the clinician's plan for the next group. The plan was missing in both records.
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Plan of Correction
Immediately following the licensing visit, the Executive Director of ARC Manor met with Program Supervisor to address this concern. The Program Supervisor will specifically address the issue of charting progress notes for group counseling in the next Clinical Staffing (May 15,2008). The Program Supervisor will also address this issue in individual supervision with all counselors and counselor assistants in the months of May and June, 2008. The Program Supervisor will spot check 2 active files monthly to ensure that the clinician's plan is included on group counseling progress notes. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on the review of four client records, the facility failed to complete a discharge summary in one of two client records where the discharge summary was required, specifically client record, # 13. The discharge summary was missing.
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Plan of Correction
In this citation,discharge summaries for the client's discharge from residential, partial hospitalization and ouptatient treatment were available in the client's record, however, the follow up form was missing in client record #13. ARC Manor contacts discharged clients at both one month and 6 months from the date of discharge. At the time of a client's complete discharge from treatment at ARC Manor, the Clinician is responsible for submitting a follow up form to the Program Supervisor. This form contains the client's name, a contact phone number, the date of discharge, and the dates of 1 and 6 month follow up. The Program Supervisor also logs data on all clients who are discharged completely from treatment in a spreadsheet. At the end of each month, the Program Supervisor prints a listing of discharged clients and cross checks this list with the follow up forms that are submitted by the Clinicians. The Program Supervisor is responsible for ensuring that all follow up forms are received by the Clinician before the forms are put into the monthly log book and scheduled for phone contact. Clinical Assistants attempt phone contact with each follow up listing in the log book. At the end of every month, all information on follow up forms is tallied by Clerical Staff(for those contacted and attempted) and then the forms are filed by Clinical Assistants. In this case, the follow up form did not appear in the chart that was reviewed because the client's discharge date was logged by the Program Supervisor as 11/30/07, however, the client was not completely discharged from treatment until January 11, 2008. The Program Supervisor caught the error on 11/30/07 when cross-checking the report, however, did not ensure that a new follow up form was submitted by the clinician on the actual discharge date of 1/11/08. The Plan of Correction in the matter is that the Program Supervisor will meet with all Clinicians in Clinical Staffing on May 15, 2008 to review the follow up policy. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on a review of four client records, the facility failed to document complete progress notes in all four client records, # 11, 12, 15 and 16. Progress notes for group counseling failed to include the clinician's plan for the next group. The plan was missing in all four records.
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Plan of Correction
Immediately following the licensing visit, the Executive Director of ARC Manor met with Program Supervisor to address this concern. The Program Supervisor will specifically address the issue of charting progress notes for group counseling in the next Clinical Staffing (May 15, 2008). The Program Supervisor will also address this issue in individual supervision with all counselors and counselor assistants in the months of May and June, 2008. The Program Supervisor will spot check 2 active files monthly to ensure that the clinician's plan is included on group counseling progress notes. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of twelve client records, the facility failed to document complete progress notes in seven records, #1, 3, 4, 5, 18, 19 and 20. Progress notes for group counseling failed to include the clinician's plan for the next group. The plan was missing in all seven client records.
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Plan of Correction
Immediately following the licensing visit, the Executive Director of ARC Manor met with Program Supervisor to address this concern. The Program Supervisor will specifically address the issue of charting progress notes for group counseling in the next Clinical Staffing on May 15, 2008. The Program Supervisor will also address this issue in individual supervision with all counselors and counselor assistants in the months of May and June, 2008. The Program Supervisor will spot check 2 active files monthly to ensure that the clinician's plan is included on group counseling progress notes. |