INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 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, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on review of the facility staff summary sheet and personnel records, the facility failed to ensure that staff persons and volunteers shall receive a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first two years of employment.Staff #3 was hired as a clinical supervisor on December 9, 2019, however at the time of the inspection had not yet received six hours HIV/AIDS training. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Programs will ensure the referenced employee will complete all required communicable disease training (i.e., HIV/AIDS) using a Department approved curriculum. This will be done by the employee scheduling and completing the HIV training. The Director of Programs will obtain a copy of the certificate of completion from the employee. The Director of Programs will document this training in the employee file.
The Director of Programs will be responsible for oversight. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the facility ' s staff summary sheet and personnel records, the facility failed to ensure that all personnel on all shifts are trained to preform assigned tasks during emergencies. Employee #2 was hired on March 15, 2021, however, did not receive emergency training until October 29, 2021. This was reviewed with the staff during licensing inspection process.
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Plan of Correction
The Director of Programs will train all new hires to perform assigned tasks during emergencies no later than seven (7) days from the date of employment. The Director of Programs will also document this instruction in the employee training attendance record. Additionally, the Director of Programs will review all new hire's personnel charts to ensure they receive fire extinguisher and emergency training within the appropriate timeframes. |
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 the client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information to the funding source in six out of seven records reviewed. Facility staff verified that billing had occurred. Client #1 was admitted October 11, 2021 and was an active at the time of the inspection.Client #2 was admitted on October 4, 2021 and discharged on December 6, 2021.Client #3 was admitted on October 4, 2021 and was an active at the time of the inspection.Client #4 was admitted on October 14, 2021 and was an active client at the time of the inspection.Client #5 was admitted on May 18, 2021 and discharged on July 29, 2021.Client #6 was admitted on April 22, 2021 and discharged on June 4, 2021. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Programs reviewed this finding for completing an informed and voluntary consent to release information form prior to the disclosure of information to the funding source with all staff during the clinical staff meeting on 1/20/2022.
Client #3 and Client #4 have a completed informed and voluntary consent to release information form to the funding source in their respective files.
The Director of Programs will ensure that all necessary informed and voluntary consent to release information forms are completed prior to the disclosure of information during chart audits.
Chart audits will be conducted on a bi-weekly basis and outcomes reviewed with clinical staff during scheduled supervision. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to assure that the client was offered a copy of the consent on all seven client records reviewed. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Programs did include a check box on the consent form indicating the client was offered a copy of the consent no later than 01/26/2022. It reads as follows: "Client was offered a copy of this consent and it was:
□ Received □ Declined."
The Director of Programs will be responsible for oversight. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the project's policy and procedures manual and client records, the project failed to include that the client may not be discriminated against based on creed. The documentation making the client aware of their rights did not include creed. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Programs did include the word creed in the policy and procedures manual as well as to the consent to treatment form no later than 01/26/2022.
The Director of Programs will be responsible for oversight. |
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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan be developed within fourteen days of admission with six out of seven client records reviewed. Client #1 was admitted on October 11, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 25, 2021; however, there was no documentation of one in the record at the time of the inspection. Client #2 was admitted on October 4, 2021 and discharged on December 6, 2021. A comprehensive treatment plan was due no later than October 18, 2021; however, there was no documentation of one in the record at the time of the inspection. Client #3 was admitted on October 4, 2021 and was an active client at the time of the inspection. A comprehensive treatment plan was due no later than October 18, 2021; however, there was no documentation of one in the record at the time of the inspection. Client #4 was admitted on October 14, 2021 and was still an active client at the time of the inspection. A comprehensive treatment plan was due on October 28, 2021; however, there was no documentation of one in the record at the time of the inspection. Client #5 was admitted on May 18, 2021 and discharged on July 29, 2021. A comprehensive treatment plan was due no later than June 2, 2021; however, there was no documentation of one in the record at the time of the inspection. Client #7 was admitted on February 26, 2021 and discharged on April 30, 2021. A comprehensive treatment plan was due no later than March 12, 2021; however, there was no documentation of one in the record 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 Director of Programs reviewed this finding for an individual treatment and rehabilitation plan to be developed within fourteen days of admission with all staff during the clinical staff meeting on 1/20/2022.
The Director of Programs will ensure that individual treatment and rehabilitation plans are developed within fourteen days of admission during chart audits.
Chart audits will be conducted on a bi-weekly basis and outcomes reviewed with clinical staff during scheduled supervision. |
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 review of the client records, the facility failed to ensure that the treatment and rehabilitation plan are reviewed and updated at least every 60 days in one out of two records reviewed. Client #3 was admitted October 4, 2021 and was active at the time of the inspection. A comprehensive treatment plan update was due no later than December 18, 2021, however there was no updated treatment plan. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Programs reviewed policy and procedures of treatment plan updates with all staff during the clinical staff meeting on 1/20/2022. Client #3 had their comprehensive treatment plan updated. The Director of Programs will ensure that treatment plans are being completed in the appropriate time frames during bi-weekly chart audits.
Chart audits will be conducted on a bi-weekly basis and outcomes reviewed with clinical staff during scheduled supervision. |
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 review of the client records, the facility failed to ensure that follow up calls were made on discharged clients based on the facility's policy manual in three out of three records reviewed.Client #5 was admitted on May 18, 2021 and discharged on July 29, 2021.Client #6 was admitted on April 22, 2021 and discharged on June 4, 2021. Client #7 was admitted n February 26, 2021 and discharged on April 30, 2021. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Programs reviewed this finding for follow-up calls not being made on discharged clients with all staff during the clinical staff meeting on 1/20/2022. The Director of Programs will ensure that follow-ups are made on discharged clients based on the facility's policy manual during chart audits.
Chart audits will be conducted on a bi-weekly basis and outcomes reviewed with clinical staff during scheduled supervision. |