INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11, 2019 of NASR Consultant Group Inc. 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:
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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 a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #4 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #4 was hired as a Counselor Assistant on April 1, 2018 and was due to have the communicable disease trainings no later than April 1, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The in-completion of the required 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training was reviewed with employee #4 on 10/28/2019. Employee #4 will be scheduled for HIV/AIDS and TB/STD training as soon as possible.
Ongoing, Facility Director will review Monthly Training reports with each counselor during scheduled supervision to ensure training requirements are being met. |
709.22 (b) (2) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(2) Identifying the project ' s purpose and philosophy directly related to drug and alcohol services.
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Observations
Based on a review of the policy and procedure manual the facility failed to identify the projects purpose and philosophy directly relating to drug and alcohol services. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 10/28/2019 Nasr Consultant Group Incorporated documented the projects purpose and philosophy directly related to drug and alcohol services in the project's policy and procedure manual as follows:
Mission, Purpose, Philosophy. The mission of Nasr Consultant Group is to encourage the well-being of individuals, families, and organizations in the community through quality, effective, and accessible treatment. Our purpose is to reduce substance abuse in our communities. Our philosophy is to meet clients where they are in terms of their readiness to change in order to elicit possible change strategies.
Ongoing, Nasr Consultant Group Incorporated's governing body will document the project's purpose and philosophy directly relating to drug and alcohol services in the project's policy and procedure manual. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.Client #4 was admitted on March 11, 2019 and was still active at the time of inspection. A treatment plan update was completed on June 5, 2019 and the next update was due no later than August 5, 2019; however, there was no update documented in the record at the time of the inspection.Client #5 was admitted on June 17, 2019 and was discharged on September 21, 2019. A treatment plan update was completed on June 17, 2019 and the next update was due no later than August 17, 2019; however, there was no update documented in the record at the time of the inspection.Client #6 was admitted on November 8, 2018 and was discharged on February 15, 2019. A treatment plan update was completed on November 13, 2018 and the next update was due no later than January 13, 2019; however, there was no update documented in the record at the time of the inspection.Client #7 was admitted on June 27, 2019 and was discharged on October 7, 2019. A treatment plan update was completed on July 2, 2019 and the next update was due no later than September 2, 2019; however, there was no update documented 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
In order to resolve the issue of treatment plan updates at least every 60 days, treatment plans and treatment plan updates was documented in client records #4, #5, #6, and #7. These corrective actions were completed no later than 11/08/2019. Counselors will provide a list of their active clients to the Program Director on a weekly basis. The Program Director will review active client records weekly and provide increased feedback to Counselors as necessary. Additionally, the Program Director will review with counselors during the weekly staff meetings for compliance with 709.92 (b). |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include progress notes, discharge summaries, aftercare plans, and follow-up information in client record #'s 1, 3, 4, 5, 6, and 7. Client #1 was admitted on September 7, 2019 and was still active at the time of inspection. The client record did not contain documentation of progress notes.Client #3 was admitted on August 26, 2019 and was still active at the time of inspection. The client record did not contain documentation of progress notes. Client #4 was admitted on March 11, 2019 and was still active at the time of the inspection. The client record did not contain documentation of a follow up. Client #5 was admitted on June 17, 2019 and was discharged on September 21, 2019. The client record did not contain documentation of a discharge summary or follow up. Client #6 was admitted on November 8, 2018 and was discharged on February 15, 2019. The client record did not contain documentation of any progress notes, aftercare plan, discharge summary and follow up. Client #7 was admitted on June 27, 2019 and was discharged on October 7, 2019. The client record did not contain documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to resolve the issue of providing a complete client record; progress notes, discharge summaries, aftercare plans, and follow-up information were completed as relative and needed in client records #1, #3, #4, #5, #6, and #7. These corrective actions were completed no later than 11/08/2019. Further, in order to resolve this issue involving progress notes, discharge summaries, aftercare plans, and follow up information; Counselors will provide a list of their active clients to the Program Director on a weekly basis. The Program Director will review active client records weekly and provide increased feedback to Counselors as necessary. Additionally, the Program Director will review with counselors during the weekly staff meetings for compliance with 709.93 (a). |