INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Arc Manor - Leechburg Satellite 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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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history including a family medical history and history of illness and symptoms in two of three client records. In addition, the facility failed to document a personal history including a recreational and sexual history in two of three client records.
The findings include:
Three client records were reviewed on February 24, 2014. Three client records were reviewed for medical and personal histories. The facility failed to document a medical history including a family medical history and history of illness and symptoms in client records # 1 and 3. The facility failed to document a personal history including a recreational and sexual history in client records # 1 and 3.
Client # 1 was admitted into treatment on April 29, 2013. A medical and personal history was completed on April 29, 2013. The medical history of client # 1 did not include a family medical history or history of illness and symptoms. The personal history of client # 1 did not include a recreational and sexual history.
Client # 3 was admitted into treatment on September 9, 2013. A medical and personal history was completed on September 9, 2013. The medical history of client # 3 did not include a family medical history or history of illness and symptoms. The personal history of client # 3 did not include a recreational and sexual history.
The project/facility director did not dispute the findings.
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Plan of Correction
ARC Manor will add the following questions to section 2 of the Psychosocial Evaluation Summary no later than March 31, 2014:
a. Describe client's recreational history (including hobbies, favorite pasttimes, and extracurricular activities)
b. Degree to which alcohol/drugs impacted client's recreational activities (client perspective and clinical perspective)
c. Describe client's sexual history (including gender identity concerns, trauma, or abuse)
d. Degree to which alcohol/drugs impacted client's sexual activities (client perspective and clinical perspective)
Similarly, Section 3 of the psychosocial evaluation summary will be updated no later than March 31, 2014 to include a specific question as follows: "Describe family medical history noting specific illnesses or symptoms"
These changes to the psychosocial evaluation summary will be reviewed with clinical staff in staffing no later than April 3, 2014.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors in three of three client records.
The findings include:
Three client records were reviewed on February 24, 2014. Three client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors in client records # 1, 2 and 3.
Client # 1 was admitted into treatment on April 29, 2013. A psychosocial evaluation was completed on April 29, 2013. The psychosocial evaluation for client # 1 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors and only included client reported historical information.
Client # 2 was admitted into treatment on April 26, 2013. A psychosocial evaluation was completed on April 26, 2013. The psychosocial evaluation for client # 2 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors and only included client reported historical information.
Client # 3 was admitted into treatment on November 26, 2013. A psychosocial evaluation was completed on September 9, 2013. The psychosocial evaluation for client # 3 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors and only included client reported historical information.
The project/facility director was interviewed throughout the licensing inspection and did not dispute the findings.
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Plan of Correction
In all of the cases identified, information regarding assets, strengths, coping mechanisms and negative factors was gathered in the psychosocial assessment, but reported only from the client's perspective. There was no clinical input offered in these areas despite the fact that the information is documented in the psychosocial under the "Clinical Assessment & Impressions Section". The need for both the client's perspective and the clinical input in these categories will be reviewed with Clinical Staff in Staffing no later than March 31st. In addition, supervisors will not sign off on any psychosocial documents that do not contain this clinical perspective. The document will be re-sent to the therapist for further information and the clinician will be held accountable for completion of the document within the established agency timeframe |