INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2015, by staff from the Division of Drug and Alcohol 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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704.9(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 an interview with the Project Director and a review of personnel records the facility failed to document the required direct observation for the counselor assistant for at least four dates.
The findings include:
One personnel record of a counselor assistant requiring documentation of direct observation was reviewed during the renewal inspection on 11/17/2015.
Employee #2 was hired as a counselor assistant on 10/05/2015, as a GED level counselor assistant. The employee counseled clients on the following dates without documentation of direct supervision of a qualified counselor or clinical supervisor: 10/14/2015, 10/30/2015, 11/13/2015 and 11/16/2015.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to resolve the issues of employee #2 who was hired as a counselor assistant; counseling clients without documentation of direct supervision of a qualified counselor or clinical supervisor: The Facility Director will be responsible for providing direct supervision while employee #2 counsels clients for the first 3 months of employment. This corrective action will be completed by of 11/26/2015. Employee #2 was informed. Documentation of direct observation will include co-signed progress notes. In order to ensure that the deficiency does not persist the responsibility of providing direct supervision while counselor assistants? counsels clients? for the first 3 months of employment has been added to the job description of the Facility Director. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted at the facility, the facility failed to ensure that only heaters that are permanently mounted or installed are located in the facility.
The findings include:
During the on-site inspection conducted on 11/17/2015, there was a Comfort Zone portable space heater plugged in and located in the Project Director's office.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/24/15, upon completion of the onsite survey, the Facility Director, met with all staff and informed them that all portable space heaters had to be removed from the facility. All portable space heaters have been removed from the facility. The Facility Director will ensure that only heaters that are permanently mounted or installed are located in the facility by conducting weekly inspections of the facility. This responsibility has been added to the job description of the Facility Director. |
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 and an interview with the Project Director, the facility failed to document a treatment plan update at least every 60 days in four of six client records reviewed.
The findings include:
Four client records that required treatment plan updates were reviewed on 11/17/2015. The facility failed to document a treatment plan update at least every 60 days in client records #2, 3, 4 and 5.
Client #2 was admitted on 05/29/2015 and was still an active client at the time of the inspection. A comprehensive treatment plan was conducted on 06/19/2015. The subsequent treatment plan update was completed on 11/02/2015.
Client #3 was admitted on 08/24/2015 and was still an active client at the time of the inspection. A comprehensive treatment plan was conducted on 09/14/2015. The subsequent treatment plan update was not completed as of the onsite inspection conducted on 11/17/2015.
Client #4 was admitted on 08/31/2015 and was still an active client at the time of the inspection. A comprehensive treatment plan was conducted on 09/08/2015. The subsequent treatment plan update was not completed as of the onsite inspection conducted on 11/17/2015.
Client #5 was admitted on 07/22/2015 and was still an active client at the time of the inspection. A comprehensive treatment plan was conducted 07/27/2015. The subsequent treatment plan update was not completed as of the onsite inspection conducted on 11/17/2015.
The findings were reviewed with the 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, a treatment plan update was documented in client records #3, #4, and #5. This corrective action was completed on 11/24/2015. There will be a monthly and a quarterly chart review conducted by the Facility Director to ensure compliance. The Facility Director will ensure overall compliance of the treatment planning process.
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