INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 7 -8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
|
Observations
Based on t physical plant inspection and an interview with the Project Director, the facility failed to ensure that each person with a hearing impairment would be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
During a physical plant inspection it was noted that there were no strobes provided in the basement level.
The basement consists of a mechanical room with mechanical equipment and a washer and dryer, a supply/ pantry room a larger room labeled staff and another laundry off of that room. The laundry rooms and lounge area are used by clients as well as staff.
The findings were discussed with facility staff at the time of the inspection.
|
Plan of Correction
In order to be in compliance with 705.10. Fire safety. (b) Smoke detectors and fire alarms; a strobe light was installed on the basement level of the facility. This will ensure persons with a hearing impairment would be alerted in the event of a fire. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of administrative documentation and an interview with facility staff, no fire drills had been conducted since February 1, 2019 when the facility first opened until a drill was conducted during the onsite inspection on November 8, 2019.
The November 8, 2019 drill was the only drill conducted.
The findings were discussed with facility staff at the time of the inspection.
|
Plan of Correction
In order to resolve the issue of monthly fire drills not being conducted. The facility will conduct unannounced fire drills at least once monthly to be in compliance with 705.10 Fire Safety. (d) Fire drills. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
|
Observations
Based on a review of the facility's policy and procedure manual, the facility lacks a procedure for the utilization of volunteers.
The facility policy and procedure states the following: Nasr encourages the utilization of volunteers to achieve organizational goals by individuals who mange programs, resources and inputs. However there is no procedure indicating how volunteers would be used or what qualifications they would need.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
In order to be in compliance with 709.26(a), the facility developed policy and procedures indicating how volunteers will be used and what qualifications they would need. That is, "Volunteers may be utilized to fulfill various roles including, but not limited to, a courtesy desk position, a counselor, a house coordinator, or a guest speaker. A volunteer must meet job qualifications for the position which they are volunteering prior to the performance of any tasks." |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
|
Observations
Based on a review of the facility's policy and procedure manual, they lacked a policy and procedure regarding the security of drugs.
While security of drugs Policy states - "Security of drugs, including, but not limited to, the loss, theft or misuse of drugs." it does not address what the policy and/or procedure is to address these items.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
In order to be in compliance with 709.32. Medication control. (5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.The facility developed policy and procedures. That is, "Any lost, stolen or misuse of medications must be reported to the director immediately, both verbally and in writing with the use of an incident report. It shall also be logged into the medical audit book. The director will then investigate the situation within 24 hours. The following procedures will then be initiated. They are:
- If the investigation shows that the client has misused the drug, she will receive a written misconduct and possibly be discharged from the program. She will also be taken to see a doctor to be checked out.
- If the investigation shows that the medication was stolen either by a client or staff member, the police will be called or that client or staff member will be discharged. Nasr Consultant Group will take responsibility and pay to have the stolen medication replaced.
- If the investigation is inclusive, the assumption will be made that staff neglect is responsible for the missing medication. The staff member in charge during the times it could have been taken will receive discipline with accordance to the personnel policy."
|
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
|
Observations
Based on a review of the facility's policy and procedure manual, they lacked a policy and procedure regarding medication errors and drug reactions.
The facility's policy and procedure simply repeats what is in regs, but, there is no policy and procedure explaining what would be done and who would be notified.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
In order to comply with 709.32. Medication control. (6) Medication errors and drug reactions. The facility developed policy and procedures. That is, "Any medication error or adverse drug reaction will be recorded in the medical audit book as well as the client record. Any client that has an adverse drug reaction will be sent to the hospital or 911 will be called dependent upon the severity of the reaction. Staff on duty will make this decision." |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
|
Observations
Based on a review of the facility's policy and procedure manual, the facility failed to have a policy and procedure to address all the required elements for 709.34(a) (3).
The facility's policy and procedure did not address death and suicide.
This was discussed with facility staff at the time of the inspection.
|
Plan of Correction
In order to address this observation, the facility developed a policy and procedure to address all the required elements for 709.34(a)(3). That is, "In the case of death, suicide, or serious injury, emergency services will be contacted immediately. The Facility Director will be informed and updated as needed and the staff member on shift at the time will complete an Incident Report prior leaving his/her shift and submit it to the Facility Director. It is the Facility Director's responsibility to submit Incident Reports to the Behavioral Health MCO, the county SCA, and/or DDAP. The Facility Director will conduct a Root Cause Analysis in order to develop recommendations for implementation. It is the responsibility if the Facility Director to develop a plan of action for the implementation recommendations." |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of client record #1 and an interview with facility staff, the facility failed to document disclosure to the client the criteria for admission, treatment completion and discharge at the time of intake.
The client was admitted on November 4, 2019. At the time of the inspection the facility had not documented that the client was informed of the criteria for admission, treatment completion and discharge. The facility did correct this at the time of the inspection by having the client sign that they were made aware of the criteria for admission, treatment completion and discharge .
|
Plan of Correction
In order to resolve this issue of documenting disclosure to the client criteria for admission, treatment completion, and discharge at the time of intake; the Program Director will review active client records weekly and provide feedback to counselors as necessary. Additionally, the Program Director will review with counselors during the weekly staff meetings for compliance with 709.51(b)(1). |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
|
Observations
Based on a review of client record #1 and an interview with facility staff, the facility failed to document that they completed a client orientation to the project with the client at the time of intake.
The client was admitted on November 4, 2019. At the time of the inspection the facility had not documented that they completed a client orientation to the project with the client at the time of intake.
The facility did correct this at the time of the inspection by having the client sign that the facility completed a client orientation to the project with the client.
|
Plan of Correction
In order to resolve this issue of documenting a completed client orientation to the project with the client at the time of intake; the Program Director will review active client records weekly and provide feedback to counselors as necessary. Additionally, the Program Director will review with counselors during the weekly staff meetings for compliance with 709.51(b)(2). |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client record #1 and an interview with facility staff, the facility failed to document a consent to treatment at the time of intake.
The client was admitted on November 4, 2019. At the time of the inspection the facility had not documented a consent to treatment from the client.
The facility did correct this at the time of the inspection by having the client sign a consent to treatment.
|
Plan of Correction
In order to resolve this issue of documenting a consent to treatment. The Program Director will review active client records weekly and provide feedback to counselors as necessary. Additionally, the Program Director will review with counselors during the weekly staff meetings for compliance with 709.51(b)(4). |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of the facility's policies and procedures manual and staff interviews, the facility failed to develop a policy and procedure for completing aftercare plans.
The facility defined what the purpose of an aftercare plan was and the elements of an aftercare plan; however, there were no timeframes for completing the aftercare plan, nor mention of how when or who would develop the aftercare plan.
The findings were discussed with facility staff during the inspection.
|
Plan of Correction
In order to address this observation, the facility developed a policy and procedure for completing aftercare plans. The facility not only defines the purpose of an aftercare plan and the elements of an aftercare plan, but the time frame for completing an aftercare plan. This includes how, when, and who would develop an aftercare plan. That is, "Aftercare plans shall be developed and completed by the counselor and client during an individual counseling session; one week before the client is successfully discharged." |