INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 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, Incorporated 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the faciltiy failed to document that a counselor assistant with a high school diploma received direct observation for the first 3 months of employment close supervisor thereafter for 9 months.Employee #5 was hired as a counselor assistant on December 9, 2019. There were no supervision notes, direct or close, documented for employee #5. At the time of the inspection, employee #5 was assigned a caseload of 13 clients.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct and document weekly supervisory sessions with Counselor Assistant (Employee #5) as of October 19, 2020. Employee #5 will receive close supervision for nine (9) consecutive months. The Program Director will ensure that any future counselor assistant will receive the required supervision. |
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 training in the 2020 training calendar year and maintain the required training hours (12) annually. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs, the facility failed to document unannounced fire drills at least once per month.There were no fire drills documented for the months of October, November and December 2019 as well as January, February and July 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will train and monitor all employees in conducting and documenting fire drills on a monthly basis. The Program Director will facilitate training by November 28, 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
The facility failed to document an annual report that included the names of board members 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
The Project Director will ensure the annual report includes the names of board members and shareholders. The annual report will be made public through the project's website. The Project Director will ensure the project's website is functioning properly no later than 11/30/2020. |
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
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven of seven client records reviewed during the annual licensing inspection conducted on October 15, 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 systems administrative personnel to create and implement a client voluntary consent form for treatment services at Nasr Consultant Group, which complies 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 in client records #1, 2 and 4.Client record #1 contained a consent to release information that was signed by the client on February 17, 2020 that did not include the information recipient. The recipient line was left blank.Client record #2 contained a consent to release information that was signed by the client on January 15, 2020 that did not include the information recipient. The recipient line was left blank.Client record #4 contained two consents to release information that were signed by the client on November 7, 2019 that did not include the information recipient. The recipient lines were left blank.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will train clinical staff in the electronic health record system to review, and document information on the consent forms which include the recipient name (i.e., person, agency, or organization) by 11/28/2020. This will be monitored during weekly chart audits. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 an individual treatment and rehabilitation plan was developed with the client in records #3 and #7.Client records were reviewed on October 15, 2020. The individualized treatment plans documented in client records #3 and #7 did not include documentation that they were completed with the client.Client #3 was admitted to treatment on February 20, 2020 and discharged on June 12, 2020. The individualized treatment plan that was dated March 21, 2020 was not signed by the client, nor was there any documentation that it was developed with the client.Client #7 was admitted to treatment on July 10, 2020 and was still active at the time of the inspection. The individualized treatment plan dated August 1, 2020 was not signed by the client and counselor until October 5, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will train clinical staff in the electronic health records system to review and document information on the individualized Treatment Plan indicating treatment plans are being completed with the client by 11/13/2020. This will be monitored by the Program Director during weekly chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every 60 days in client records #5, #6 and #7.Client records were reviewed on October 15, 2020. Client records #5, 6 and 7 did not include documentation of treatment plan updates at least every 60 days.Client #5 was admitted on June 18, 2020 and is still active in treatment. An individualized treatment plan was documented on June 24, 2020. A treatment plan review and update was due to be completed by August 24, 2020. The treatment plan review and update was documented on September 17, 2020.Client #6 was admitted on July 3, 2020 and is still active in treatment. An individualized treatment plan was developed on July 7, 2020. A treatment plan review and update was due to be completed by September 7, 2020. There was no treatment plan review and update documented in client record #6.Client #7 was admitted on July 10, 2020 and is still active in treatment. An individualized treatment plan was developed on August 1, 2020. A treatment plan review and update was due to be completed by October 1, 2020. There was no treatment plan review and update documented in client record #7.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will train clinical staff in the electronic health record system to review, and document information on the individualized Treatment Plan (every 60 days) with the client and obtaining the client signature by 11/15/2020. This will be monitored by the Program Director during weekly chart audits. |
709.93(a)(11) 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:
(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 #1, 2, 3 and 4.Client records were reviewed on October 15, 2020. Based on agency policy, follow up contact is to be completed within 7 days of discharge. Client records #1, 2, 3 and 4 did not include documentation of follow up.Client #1 was admitted on February 17, 2020 and discharged on June 22, 2020. There was no follow up contact documented in client record #1.Client #2 was admitted on January 15, 2020 and discharged on June 1, 2020. There was no follow up contact documented in client record #2.Client #3 was admitted on February 20, 2020 and discharged on June 12, 2020. There was no follow up contact documented in client record #3.Client #4 was admitted on November 7, 2019 and discharged on May 15, 2020. There was no follow up contact documented in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will train clinical staff in the electronic health record system to review, and document information on follow-up forms within 7 days after the client has been discharged from the program by 11/15/2020. This will be monitored by the Program Director during weekly chart audits. |