INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 29, 2021, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Nasr Consultant Group, Inc. 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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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill logs and an interview with the facility director, the facility failed to set off the fire alarm or smoke detector during each fire drill. Fire drills between December 2020 and July 2021 were reviewed. The fire drills that did not document setting off the fire alarm or smoke detector occurred on:
December 8, 2020April 14, 2021
January 28, 2021April 28, 2021
February 17, 2021May 18, 2021
February 21, 2021June, 21, 2021
March 22, 2021June 28, 2021
March 31, 2021
These findings were reviewed with facility staff during the licensing process.
This is a repeated citation from the last inspection dated October 14, 2020.
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Plan of Correction
1. The Project Director will facilitate training for all Staff on conducting and documenting Fire Drills utilizing the Fire Alarm Pull Box and Smoke Detectors by August 25, 2021.
2. Project Director will conduct weekly audits of documented Fire Drills in Fire Drill Log to ensure Nasr Residential maintains compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 30 days in three of seven records. Client records #1, 2 and 5 did not include documentation that treatment plans were reviewed and updated at least every 30 days.
Client #1 was admitted on February 23, 2021 and is currently an active client. There were treatment plan updates dated March 23, 2021 and May 3, 2021. There was no update documented in April 2021.
Client # 2 was admitted on March 1, 2021 and is currently an active client. There were treatment plan updates completed on March 23, 2021 and May 13, 2021. There was no treatment plan update documented in April 2021.
Client # 5 was admitted on December 14, 2020 and discharged on April 2, 2021. The last treatment plan update was dated February 25, 2021. There were no treatment plan updates documented in March 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeated citation from the inspection dated October 14, 2020.
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Plan of Correction
1. Project Director is responsible for clients, 1, 2 and 5 after primary counselor resigned on April 28, 2021.
2. Project Director will place Documentation Deficiency Forms in clients, 1, 2 and 5 clinical charts for incomplete treatment plans prior to April 28, 2021 by August 16 2021.
3. Project Director will review and provide updated treatment plans for client's 1, 2 and 5 by August 25, 2021.
4. Project Director will conduct weekly chart audits to ensure treatment plans meet compliance. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to document counseling on a regular and scheduled basis in two of seven records. Client records # 1 and 2 did not include documentation of regularly scheduled counseling sessions.
Client # 1 was admitted on February 23, 2021 and is currently an active client. There were no counseling services documented for the time period between March 19 - April 12, 2021and then again from May 10, 2021 to current.
Client # 2 was admitted on March 1, 2021 and is currently an active client. There were no counseling sessions documented for the time period between May 3-June 8, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeated citation from the last inspection dated October 14, 2020.
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Plan of Correction
1. 1. Project Director is responsible for clients, 1, 2 and 5 after primary counselor resigned on April 28, 2021.
2. Project Director will place Documented Deficiency Forms in clients' 1 and 2 charts for missing sessions prior to April 28, 2021.
3. Project Director will document all weekly Counseling Sessions that were conducted for Clients, 1 and 2 in Electronic Health System after April 28, 2021 by August 21, 2021.
4. Project Director will conduct bi-weekly chart audits to ensure that this deficency is not repeated.
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document work done by the client at the facility is an integral part of the treatment and rehabilitation plan. Clients are assigned household tasks as part of their treatment. There was no work therapy documented on treatment plans reviewed in three of seven records.
Client # 2 was admitted on March 1, 2021 and is currently an active client.
Client # 3 was admitted on April 26, 2021 and is still an active client.
Client # 4 was admitted on July 2, 2021 and is still an active client.
These findings were reviewed with facility staff during the licensing process.
This is a repeated citation from the last inspection dated October 14, 2020.
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Plan of Correction
1. Project Director is responsible for client Intake/Admissions.
2. Project Director will implement Work Therapy Goal in the Electronic Health System on the Preliminary Treatment Plan by August 25, 2021
3. Project Director will implement Work Therapy Goal in the Comprehensive and Updated Treatment Plans by August 25, 2021. |