INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2022, 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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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 three out of four applicable records reviewed.Client #1 was admitted on September 13, 2022 and was still active at the time of the inspection. A treatment plan was completed on September 13, 2022, and the next update was due no later than November 13, 2022; however, there was no documentation that one was completed. Client #2 was admitted on August 11, 2022 and was still active at the time of the inspection. A treatment plan update was completed on August 11, 2022, and the next update was due no later than October 11, 2022; however, it was completed on October 13, 2022. The next update was due no later than December 13, 2022; however, there is no documentation that one was competed.Client #3 was admitted on July 29, 2022 and was still active at the time of the inspection. A treatment plan was completed on August 4, 2022, and the next updates were due no later than October 4, 2022, and December 4, 2022; however, there is no documentation that updates were completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will review and complete treatment and rehabilitation plans every 60 days. The Lead Counselor will conduct quality assurance reviews weekly as well as utilize the tag feature within the Electronic Health Record system to send reminders to ensure treatment plan updates are being conducted by the counselors.
The Lead Counselor will update the Director of Programs monthly on treatment plan compliance. The Director of Programs will address non-compliance in this area during individual supervision. |
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 two out of six applicable records reviewed.Client #1 was admitted on September 13, 2022 and was still active at the time of the inspection. The treatment plan dated September 13, 2022, indicated two individual sessions per month. The client had one session on November 7, 2022; however, there was no documentation that the client received any further treatment and there was no documentation of no shows. Client #4 was admitted on October 24, 2022 and was still active at the time of the inspection. The treatment plan dated October 24, 2022, indicated individual sessions twice a week. According to the client record, the only documented session was on November 25, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will conduct quality assurance reviews on a weekly basis to ensure that clients receive counseling services according to their individual treatment plans.
The Lead Counselor will update the Director of Programs monthly on treatment plan compliance. The Director of Programs will address non-compliance in this area during individual supervision. |
709.93(a)(8) 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:
(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 procedures of once every 30 days in five out of seven client records reviewed. Client #1 was admitted on September 13, 2022 and was still active at the time of the inspection. A case consultation was due no later than October 13, 2022: however, was completed on October 24, 2022, and there was no documentation of additional case consultations. Client #2 was admitted on August 11, 2022 and was still active at the time of the inspection. A case consultation was due no later than September 11, 2022; however, there is no documentation that a case consultation occurred. Client #3 was admitted on July 29, 2022 and was still active at the time of the inspection. A case consultation was due no later than August 29, 2022; however, there is no documentation that a case consultation occurred. Client #4 was admitted on October 24, 2022 and was still active at the time of the inspection. A case consultation was due no later than November 24, 2022; however, there is no documentation that a case consultation occurred.Client # 5 was admitted on August 8, 2022 and was discharged on November 4, 2022. A case consultation was due no later than September 8, 2022; however, there is no documentation that a case consultation occurred. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will complete quality assurance reviews on a weekly basis with each member of the clinical team to ensure that case consultations are being completed once every 30 days for each client.
The Lead Counselor will update the Director of Programs monthly on treatment plan compliance. The Director of Programs will address non-compliance in this area during individual 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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of two applicable discharged records reviewed.Client #7 was admitted on July 18, 2022 and was discharged on October 3, 2022. This is a repeat citation from January 8, 2019, October 11, 2019, October 15, 2020, and December 20, 2021, licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a client is discharged from the outpatient program; the Lead Counselor will send the follow-up form to the Administrative Assistant within the Electronic Health Record (EHR) system. The Administrative Assistant will attempt to contact each discharged client as well as complete the follow-up form within 30 days but not less than 10 days.
Once the follow-up form is complete; the Administrative Assistant will send the follow-up form back to the Lead Counselor to review. The Lead Counselor will review the completed follow-up form to ensure completeness.
The Lead Counselor will update the Director of Programs monthly on follow-up compliance. The Director of Programs will address non-compliance in this area during individual supervision. |
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
The facility failed to comply with plans of corrections approved by the department. The facility received citations for follow up information during the annual licensing inspections on January 18, 2019, October 11, 2019, October 20, 2020, and December 20, 2021. Plans of corrections to gain compliance were completed by facility staff for the 2019, 2020 and 2021 and approved by DDAP staff; however, the facility was cited for failing to complete follow up information again during this licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Our Director of Programs will be responsible for monitoring approved plans of correction. This will be done by the Lead Counselor conducting weekly quality assurance reviews of client charts. The Lead Counselor will update the Director of Programs monthly on the compliance of all plans of correction. The Director of Programs will address non-compliance in this area during individual supervision. |