INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25, 2024, 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.Client #1 was admitted to the residential rehabilitation level of care on October 28, 2024 and discharged against facility advice on November 18, 2024. The facility failed to follow their policy related to against facility advice discharges of calling the emergency contact within twelve hours. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor retrained all clinical staff on facility policy regarding clients being discharged against facility advice. This training occurred on December 2, 2024. We addressed calling the emergency contact within 12 hours. The clinical supervisor will continue to monitor this during bi-weekly chart reviews with clinical staff. |
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 the review of client records, the facility failed to document case consultations within the facility ' s policy and procedure manual timeframe in one out of one applicable client records. The facility's policy and procedures manual states that the case consult will occur monthly. Client #4 was admitted on October 22, 2024 and was still active at the time of the inspection. A case consultation was due no later than November 22, 2024; however, there was no documentation that one occurred. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This oversight was corrected on 11/25/2024. Additionally, the clinical supervisor met with all clinical staff, and completion dates for case consultation notes were addressed as a reminder of the importance of adhering to the completion timeframe. The clinical supervisor will continue to monitor this during bi-weekly chart reviews with clinical staff. |