INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on October 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of training records, the project director failed to document 12 hours of training for the 2019 training year.
The project director did not have training hours documented for the 2019 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will attend scheduled trainings in the 2020 Training Calendar year and maintain required training hours (12) by December30, 2020. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
During the time of the onsite inspection, there was an active water leak that was spraying water out onto the floor, making the bathroom on the " B Wing " unusable. There was a maintenance person working on the leak while the inspector was there; however, there was no water in the facility for several hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Water Break on 10/14/2020 in the
B Wing bathroom at Nasr-residential was contained and water was back on by 3:00PM. On October 15, 2020 The pipes from Shower in B Wing were removed. This Bathroom was never utilized by residents for bathing. |
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, the facility failed to set off the fire alarm or smoke detector during each fire drill.
The fire drill logs were reviewed on October 14, 2020. Several of the fire drills had " audible device " checked instead of fire alarm/smoke detector. The months of December 2019 and September 2020 did not have documentation of a fire drill with the fire alarm or smoke detector set off.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(1) Program Director revised Fire Drill Log Form and removed the Audible Device selection on October 22, 2020.
The Program Director will train all Employees in conducting Fire Drills and documentation.
(2) Program Director will train all Staff to conduct various Fire Drills utilizing the fire alarm and smoke detector by November 30. 2020. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual report that included the names of board of directors and shareholders. Only the name of the executive director was documented. In addition, the report was not made public. The project director reported it was on the website, but the website was inoperable at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will provide an Annual Report which includes the names of the Board of Directors and Share holders by 11/20/2020.
2. Project Director will make Annual Report available to the Public and Repair Nasr Consultant's Inc.'s Website to view Annual Report by 11/20/2020.
3. Project Director will meet with Board of Directors and Share Holders quarterly to review and discuss annual report beginning 1/15/2021.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of six client records reviewed on October 14, 2020.
The facility utilized a paper consent to treatment form prior to initiating an electronic record keeping system. This form is a combination of a consent to treatment and a consent to release information. The client is required to sign the consent form during the intake process in order to receive treatment services. This is not a voluntary consent, as the client cannot receive treatment without also consenting to release information at the same time. There are statements notifying the client that confidentiality cannot not be maintained when a plan is mentioned to harm another person and when a court requires information. This is not in compliance with 4 Pa Code 255.5. The electronic consent to treatment is also combined with a consent to release information. The electronic consent to treatment includes a statement in which indicates that all or part of the client record may be disclosed to any person or corporation which is or may be liable for facility charges. This is also not in compliance with 4 Pa Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project director and Program Director will consult with Electronic Health Records System Administrative Personnel to create and implement individual Client Voluntary Consent Forms for Treatment Services at Nasr Residential and to Release /Obtain Information to maintain compliance with 4 PA Code 255.5 by 11/20/2020. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the name of the person, agency or organization to whom the disclosure will be made.
Client record #4 contained a consent to release information that was signed by the client on March 6, 2020 that did not include the information recipient. The recipient line was left blank.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will train Clinical Staff in the Electronic Health System to document the recipient on all Consent forms when requesting to obtain or release information about client.
Project Direct will conduct bi-weekly chart audits to ensure Nasr Residential maintains required documentation of recipients and signatures starting 11/5/2020. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative documentation, the facility failed to document inspections of the medication storage area. There were no inspections of the medication storage area documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Program Director will implement Medication Management Document to monitor the Storage of Medication, Storage Area and Disposal of Medication by 11/30/ 2020.
2. Program Director will train all Staff on Medication Management Document and protocol for storage and disposal by 11/12/2020
3. Program Director will monitor Medication Management Document on weekly basis starting 11/15, 2020. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations in client records #4, 5 and 6.
Client #4 was admitted on March 2, 2020 and discharged July 2, 2020.
Client #5 was initially admitted November 22, 2019 and then re-admitted on January 24, 2020. She was discharged from the program, but the date is unknown.
Client #6 was admitted on February 4, 2020 and discharged on April 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review each referral to Nasr Residential Program to ensure that a Physical Examination has been completed prior to admission beginning 11/5/2020. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan was developed with a client within 14 days of admission in client records #1 and 6.
Client #1 was admitted on July 30, 2020. A treatment plan was documented on August 14, 2020; however, it was not signed by the client and there was no documentation regarding the development of the plan with the client.
Client #6 was admitted on February 4, 2020 and discharged on April 14, 2020. A comprehensive treatment plan was due to be developed with the client within 14 days of admission, which would have been February 18, 2020. There was no comprehensive treatment plan documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records System to document and complete Preliminary (14 days), Comprehensive and Updated Treatment Plans(30 days) on each client by 11/6/2020
2. Project Direct will conduct bi-weekly chart audits to ensure Nasr Residential Clinical Staff are in compliance with completing Individualized Treatment Plans for each client every 30 days after the Preliminary Treatment Plan at Admission. |
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.
Client records #1, 4 and 6 did not include documentation that treatment plans were reviewed and updated at least every 30 days.
Client #1 was admitted on July 30, 2020 and is currently an active client. The last treatment plan was documented on August 14, 2020. There were no treatment plan updates documented in September or October 2020.
Client #4 was admitted on March 2, 2020 and discharged on July 2, 2020. The last treatment plan was documented on April 15, 2020. There were no treatment plan updates documented in May or June 2020.
Client #6 was admitted on February 4, 2020 and discharged on April 14, 2020. The last treatment plan was documented on February 4, 2020. There were no treatment plan updates documented in March or April 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records System to document and complete Individualized Treatment Plans every 30 days after client completes their Preliminary Treatment Plan (14 days) by 11/7/2020.
2. Project Director will conduct bi-weekly chart audits, Clinical Staff Meetings and Supervisory Sessions to ensure Nasr Residential Clinical Staff maintain compliance with documenting and completing Preliminary, Comprehensive and Updated Treatment Plans for each client on caseload. |
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 client records #4, 5 and 6.
Client #4 was admitted to treatment on March 2, 2020 and discharged on July 2, 2020. There were no counseling services documented for the time period of March 6 - April 13, 2020 and then again from June 23, 2020 - July 2, 2020.
Client #5 was last admitted to treatment on January 24, 2020 and discharged on an unknown date. There were no counseling services documented for the time period of January 24 - 29, 2020.
Client #6 was admitted to treatment on February 4, 2020 and discharged on April 14, 2020. There were no counseling services documented for the time period of March 11 - April 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records System to document and complete Individual Counseling Session with client caseload at a minimum of one time per week by 11/7/2020.
2. Project Direct will conduct bi-weekly chart audits to ensure Nasr Residential Clinical Staff are in compliance with completing Individualized Counseling Sessions for each client on caseload one time per week. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete record of service provided in client records #4, 5 and 6.
Client #4 was admitted to treatment on March 2, 2020 and discharged on July 2, 2020. The record of service was blank for the time period of March 6 - April 13, 2020 and then again from June 23, 2020 - July 2, 2020.
Client #5 was last admitted to treatment on January 24, 2020 and discharged on an unknown date. The record of service was blank for the time period of January 24 - 29, 2020. The last entry was on February 2, 2020. It is unknown when the client was discharged.
Client #6 was admitted to treatment on February 4, 2020 and discharged on April 14, 2020. The record of service was blank for the time period of March 11 - April 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Client Record of Service was implemented in the Electronic Health Records System in May of 2020. Client Records #4, #5 and #6 were not in the Electronic Health System. Client Records were on paper.
The Electronic Health System tracks all record of service to date.
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709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in client records #1, 2, 4 and 5.
Case consultation forms were completed and documented in client records #1, 2, 4 and 5; however, there is no evidence that a consultation occurred. The case consultation forms are written as notes and signed by the counselor, there are no other names or signatures documented on the form to indicate that a consultation took place.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records System to document and complete Case Consultations on each client on their caseload which will consist of one Case Consultation per month by 11/20/ 2020.
2. Project Direct will conduct bi-weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff are in compliance with completing a Case Consultation for each client every 30 days and obtaining three or more signatures. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in client records #4 and 5.
Client records were reviewed on October 14, 2020. Client records #4 and 5 did not include documentation of a discharge summary.
Client #4 was admitted on March 2, 2020 and discharged on July 2, 2020. There was no discharge summary documented in client record #4.
Client #5 was last admitted on January 24, 2020 and discharged on an unknown date; however, it is known that this client has not resided in the facility for several months. There was no discharge summary documented in client record #5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records System to document and complete Discharge Summaries on each client on their caseload by 11/15/2020.
2. Project Director will conduct bi-weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff are in compliance with completing a Discharge Summaries on all clients on their caseload. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up contact in client records #4, 5 and 6.
Client records were reviewed on October 14, 2020. Based on agency policy, follow up contact is to be completed within 7 days of discharge. Client records #4, 5 and 6 did not include documentation of follow up.
Client #4 was admitted on March 2, 2020 and discharged on July 2, 2020. There was no follow up contact documented in client record #4.
Client #5 was last admitted on January 24, 2020 and discharged on an unknown date; however, it is known that this client has not resided in the facility for several months.. There was no follow up contact documented in client record #5.
Client #6 was admitted on February 4, 2020 and discharged on April 14, 2020. There was no follow up contact documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records (OPUS)System to document and complete Follow Up Form on each client on their caseload by 11/12/ 2020.
2. Project Direct will conduct bi-weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff are in compliance with completing a Follow Up Form for each client on caseload within 7 days of Client's Discharge. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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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 project 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 any of the treatment plans reviewed in client records #1, 2, 3, 4, 5 and 6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director trained Clinical Staff in the Electronic Health Records System to document Work Therapy in New Admission's Preliminary Treatment Plan Treatment Plan on 11/4/2020.
2. Project Director will conduct chart audits on all admissions to ensure Nasr Residential Clinical Staff are implementing and documenting Work Therapy in the Preliminary Treatment Plan.
3. Program Director will conduct bi-weekly chart audits on Comprehensive and Updated Treatment Plans to ensure that Work Therapy is documented as a continued goal. |