INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the January through November 12, 2024 fire drill logs during the inspection, the facility failed to document the exit route used on May 29 and June 30, 2024 fire drills, and if there were any problems that were encountered during the June 20, 2024 fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The fire logs in question have been corrected and updated. The exit routes on May 29, 2024, and June 30, 2024, fire logs are now documented. It was noted on the fire log on June 20, 2024, that no problems were encountered. These corrections took place on 12/20/2024.
The Facility Director will retrain all staff members to complete the fire log form correctly.
Facility Director will ensure that all staff complete and sign the training evaluation form.
The Facility Director will complete the Fire Drill Log monthly to ensure that it is completed correctly by the 25th of each of Month.
This will be implemented by 2/25/2025 and all new staff will complete this training within 2 weeks of hiring date in the future. |
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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three out of seven records reviewed.
Client #2 was admitted on November 14, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #4 was admitted on August 14, 2024 and discharged on September 30, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
Client #5 was admitted on October 25, 2024 and discharged on November 25, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This is a repeat citation from the December 19, 2023 and June 21, 2024 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will implement training on Releases of Information (ROI) to ensure that the ROI is current for the Active clients.
**Training will consist of defining types, reason/purpose, and importance.
** Training will be provided to all current staff and all new/incoming staff within 2 weeks of their hire date.
Facility Director will ensure that all staff complete and sign training evaluation form which will be placed in their Employee File.
The Internal Quality Assurance Specialist will also conduct audit of random client files weekly to ensure that all ROI's are current.
The Facility Director will review all client files weekly with Staff to ensure all ROI's are current for all active clients.
The Project Director will conduct bi-weekly audit reviews of files with the Facility Director to ensure that ROI's are current for all active clients.
This will be implemented by 2/25/2025. |
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 that an individual treatment and rehabilitation plan was developed with the client per the facility ' s policy and procedure manual in six out of seven records reviewed. The facility ' s policy and procedure manual states intensive outpatient clients need an individual treatment plan developed within fourteen days of admission and outpatient clients need an individual treatment plan developed within twenty-one days of admission.
Client #1 was admitted to the intensive outpatient level of care on September 6, 2024 and was still active at the time of the inspection. An individual treatment plan was due no later than September 20, 2024; however, it was completed on September 23, 2024.
Client #2 was admitted to the intensive outpatient level of care on November 14, 2024 and was still active at the time of the inspection. An individual treatment plan was due no later than November 28, 2024; however, it was completed on December 13, 2024.
Client #4 was admitted to the intensive outpatient level of care on August 14, 2024 and discharged on September 30, 2024. An individual treatment plan was due no later than August 28, 2024; however, there was no documentation that one was completed.
Client #5 was admitted to the intensive outpatient level of care on October 25, 2024 and discharged on November 25, 2024. An individual treatment plan was due no later than November 8, 2024; however, it was completed on November 11, 2024.
Client #6 was admitted to the intensive outpatient level of care on May 28, 2024 and discharged on August 27, 2024. An individual treatment plan was due no later than June 12, 2024; however, it was completed on July 2, 2024.
Client #7 was admitted to the intensive outpatient level of care on June 11, 2024 and discharged on September 11, 2024. An individual treatment plan was due no later than June 25, 2024: however, it was completed on July 2, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was due to an error regarding outpatient and intensive outpatient treatment requirements. According to the ASAM criteria, outpatient treatment (OP) is less than 9 hours weekly, and intensive outpatient (IOP) treatment is 9-19 hours weekly.
The Project Director will implement a refresher training on ASAM criteria for OP vs. IOP treatment for the Facility Director. The Facility Director will retrain all staff on the ASAM criteria related to OP vs. IOP treatment, timelines for the initial comprehensive treatment plans, and the updated treatment plans. All staff will sign and complete the training evaluation form.
The Facility Director will review files weekly. The internal Quality Assurance Specialist will audit files randomly weekly. The Project Director will conduct biweekly audit reviews with the Facility Director.
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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 within the regulatory timeframe in two out of three applicable records reviewed.
Client #1 was admitted on September 6, 2024 and was still active at the time of the inspection. A treatment plan was completed on October 4, 2024 and the next update was due no later than December 4, 2024; however, the next update was completed on December 13, 2024.
Client #7 was admitted on June 11, 2024 and discharged on September 11, 2024. A treatment plan was completed on July 2, 2024 and the next update was due no later than September 2, 2024: however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will retrain all staff on the timelines for the updated treatment plans.
Facility Director will ensure that All staff sign and complete the training evaluation form.
The Internal Quality Assurance Specialist will audit files randomly weekly.
The Project Director will conduct biweekly audit reviews with the Facility Director.
The Facility Director will review files weekly with Staff to ensure Treatment plans are updated timely.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #3 was admitted on October 8, 2024 and was still active at the time of the inspection. The treatment plan dated October 24, 2024 indicated two individual sessions and one group session a week. There was no documentation of the client receiving group therapy the week of December 9, 2024. In addition, there was no documentation that the client received individual therapy the weeks of November 11, 2024, December 2, 2024 and December 9, 2024. There was only one documented individual session the week of November 25, 2024.
Client #6 was admitted on May 28, 2024 and discharged on August 27, 2024. The treatment plan dated July 2, 2024 indicated one individual a week and three group sessions weekly. There was no documentation that the client received group therapy the weeks of July 8 and July 22, 2024. The weeks of July 15, 31, August 5, 12 and 19, 2024 only had documented one group session a week.
Client #7 was admitted on June 11, 2024 and discharged on September 11, 2024. The treatment plan dated July 2, 2024 indicated two individual and one group session weekly. There was no documentation that the client received individual therapy the week of July 31, 2024. In addition, there was no documentation that the client received group therapy the weeks of July 16 and July 23, 2024.
This is a repeat citation from the December 15, 2022, December 19, 2023 and June 21, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will retrain all staff on treatment plan writing, scheduling, and chart notation (particularly noting client reschedules and cancellations). All staff will sign and complete the training evaluation form.
The Facility Director will review files weekly. The internal Quality Assurance Specialist will audit files randomly weekly. The Project Director will conduct biweekly audit reviews with the Facility Director. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring client confidentiality was submitted and approved by the Department for the December 19, 2023 and June 21, 2024 licensing inspections. Ensuring client confidentiality was again found to be a deficiency in the December 18, 2024 licensing inspection.
A plan of correction for ensuring that the clients received counseling services according to their individual treatment plan was submitted and approved by the Department for the December 15, 2022, December 19, 2023 and June 21, 2024 licensing inspection. Ensuring that the client received counseling according to their individual treatment plan was again found to be a deficiency in the December 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Internal Quality Assurance Specialist will audit files randomly weekly to ensure that all plans of correction are being followed.
The Facility Director will review files weekly with Staff to ensure that all plans of correction are being followed.
The Project Director will conduct biweekly audit reviews with the Facility Director to ensure that all plans of correction are being followed.
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