INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 2023, and physical plant inspection conducted on December 20, 2023, 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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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and staff schedule provided by the facility, the facility failed to provide awake staff coverage 24 hours a day. There was no coverage documented the hours of: 7am-8am on September 26, October 3, 10, 11, 12, 17, 18, 19, 24, 25, 26, 2023.7am-9am on September 25, October 2, 6, 9, 16, 20, 23, 31, November 1, 2, 6, 7, 8, 9, 13, 14, 15, 16, 2023.7am-3pm on October 7, 8, 15, 21, 22, 29, November 5, 12, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director is responsible for creating Staff Schedule that shows coverage 24 hours in Facility.
2. Project Director did not revise schedule or fill in time gaps on schedule when Staff requested off showing that there was Staff coverage in facility.
3. Project Director will revise Staff Schedule as needed to refect 24 hour Staff Coverage at Nasr Residential. |
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 a review of personnel records, the facility failed to provide supervision of a counselor assistant based on their education and clinical experience in one applicable record reviewed. Employee # 2 was hired as a counselor assistant with a high school diploma on March 1, 2023, and was still in this position at the time of the inspection. Employee #2 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. There was no documentation that direct observation occurred since employee #2 was hired. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Employee #2 is no longer employed at Nasr Residential.
2. The Project Director will facilitate and document direct observation for any Counselor Assistants hired for the first 3 months of employment.
3. The Project Director will conduct close supervision and document all Individual Counseling Sessions conducted by Counselor Assistants hired for the next 9 months.
4. The Project Director will meet with Counselor Assistants in documented Supervisory Session to discuss observations on a weekly or as needed basis. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and staff schedule provided by the facility, the facility failed to provide a sufficient number of staff persons with CPR certification and first aid training onsite during the project's hours of operation. A review of the staff schedule provided for October 15, 2023 - December 17, 2023 the facility did not have any CPR or first aid coverage on the following days and times:October 22, 2023 there was no coverage from 7am-3pm.October 23, 2023 there was no coverage from 7am - 9am.October 24, 2023 there was no coverage from 7am-8am and 10pm-11pm.October 25, 2023 there was no coverage from 7am-8am.October 26, 2023 there was no coverage from 7am-8am.October 29, 2023 there was no coverage from 7am-3pm.October 30, 20213 there was no coverage from 7am-9am and 1pm-3pm.October 31, 2023 there was no coverage from 10pm-11pm.November 1, 2023 there was no coverage from 7am-9am and 10pm-11pm.November 2, 2023 there was no coverage from 7am-9am.November 5, 2023 there was no coverage from 7am-3pm.November 6, 2023 there was no coverage from 7am-9am. November 7, 2023 there was no coverage from 7am-9am. November 8, 2023 there was no coverage from 7am-9am. November 9, 2023 there was no coverage from 7am-9am. November 12, 2023 there was no coverage from 7am-3pm.November 13, 2023 there was no coverage from 7am-9am. November 14, 2023 there was no coverage from 7am-9am. November 15, 2023 there was no coverage from 7am-8am.November 16, 2023 there was no coverage from 7am-9am.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. All Staff were certified in CPR/First Aid at time of inspection.
2. Based on the citation regarding the Staff Schedule not showing coverage, this is the result.
3. Project Director is responsible for creating Staff Schedule that shows coverage 24 hours in Facility.
4. Project Director did not revise schedule or fill in time gaps on schedule when Staff requested off showing that there was Staff coverage in facility.
5. Project Director will revise Staff Schedule as needed to refect 24 hour Staff Coverage at Nasr Residential. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the facility physical plant inspection, the facility failed to keep hot water temperature to not exceed 120 degrees Fahrenheit in the bathrooms. The bathroom water temperature was 132 degrees Fahrenheit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director called facility Maintenance to reinspect furnace and water heater on January 22, 2024
2. Maintenance personnel retrained and instructed Project Director on monitoring Temperature Dial on Furnace and water heater on.
3. Project Director assisted Maintenance Personnel returned to Nasr-Residential on January 23, 2024, by taking water temperature in Kitchen and Bathroom sinks in A and B Wing which read 115F on thermometer.
4. Project Director will create and implement temperature log and train all Staff to conduct water temperature checks by February 2, 2024.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the bathroom by exhaust fan or window.The bathroom did not have an exhaust fan and the window that was in the bathroom was screwed shut.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Project Director called Facility Maintenance to repair B Wing Bathroom to provide ventilated by removal of screws from bathroom window.
2. On January 30, 2024, screws were removed, and a mesh screen was installed outside window to ventilate B Wing Bathroom.
3. All Staff will conduct daily inspections of the physical plant on a hourly basis.
4. All Staff will communicate to Project Director about any maintenence concerns or repairs needed by end of shift.
5. Project Director will meet with
Exective Director to conduct monthly inspections of the physical plant to ensure that all facility maintenence and repairs are completed.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The resident bathroom shower handle was broken and difficult to turn on and off and the bath spout was broken and not attached to the wall.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director called facility Maintenance to repair shower handle and spout in A Wing Bathroom.
2. On January 30, 2024, shower handle and spout were repaired in A Wing Bathroom.
3. All Staff will conduct daily inspections of the physical plant on a hourly basis.
4. All Staff will communicate to Project Director about any maintenence concerns or repairs needed by end of shift.
5. Project Director will meet with
Exective Director to conduct monthly inspections of the physical plant to ensure that all facility maintenence and repairs are completed. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area after each usage. There were cooking utensils were being stored in an open container on the countertop. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train and instruct all Staff to monitor Kitchen Area of Nasr Residential to assure that on all cooking and eating utensils are clean and placed in an enclosed area after each use.
2. All Staff will conduct daily inspections of the Kitchen Area on a hourly basis to ensure all kitchen utensils are in enclose area.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. Emergency exit doors were locked from the inside.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director called facility maintenanc remove top inside lock from the Exit Door on 1/1/27/2024.
2. Project Director will conduct daily inspection of the facilty plant to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. |
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 the facility ' s policy and procedure manual, the facility failed to provide a written plan for the coordination of client treatment and rehabilitation services which includes written procedures for the management of treatment/rehabilitation services for clients; specifically, the times/events case consultations are completed and procedures for contacting the emergency contact person when a client leaves against medical advice. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Executive Director of Nasr Consultants-Residential will revise and implement a written plan for the coordination of client treatment and rehabilitation services to include written procedures for the times/events case consultations are completed and procedures for contacting the emergency contact person when a client leaves against medical advice.
2. Project Director will train Clinical Staff on written procedures of times and events for documentation of Case Consultations.
3. Project Director will train Clinical Staff on written procedures of contacting the Client's Emergency Contact when Client leaves against medical advice. |
709.24 (b) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(b) The project shall maintain a current community resource listing of other health and social service agencies.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to maintain a current community resource listing of other health and social service agencies in the appendix section as indicated in the manual. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. A 2023 Community Resource Listing of other health and social service agencies was obtained on January 21, 2024, from Dauphin County Human Services and implemented in Nasr Consultants Policy & Procedure Manual Appendix.
2. Project Director placed Community Resource Listing of other health and social service agencies in facility for review by Staff and Residents.
3. Project Director will obtain a 2024 Community Resource Listing from Dauphin County Human Services when published.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the project ' s fiscal management, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the fiscal year 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Executive Director will obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services for fiscal year 2022.
2. Exexcutive Director will obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services for fiscal year 2023.
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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 five of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in records # 1, 3, 5, 6 and # 7. Client # 1 was admitted on August 21, 2023, and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated the funder was being billed for services. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.Client # 3 was admitted on September 21, 2023, and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated the funder was being billed for services. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023. A review of client records and discussion with facility administration indicated the funder was being billed for services. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.Client # 6 was admitted on June 21, 2023, and was discharged on November 3, 2023. A review of client records and discussion with facility administration indicated the funder was being billed for services. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.Client # 7 was admitted on June 9, 2023, and was discharged on June 25, 2023. A review of client records and discussion with facility administration indicated the client ' s funder was being billed beginning at admission, however, the consent to release form was not signed by the client until June 12, 2023. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the December 14, 2022 annual licensing inspection.
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Plan of Correction
1. The Project Director will train Clinical Staff in the Electronic Health System to document the recipient on all Consent forms when requesting to obtain or release information about client.
2. Furthermore, Nasr Consultant Group has hired a licensed professional counselor to serve as the project's Quality Assurance Specialist. The project has also developed a Quality Assurance Checklist that consists of checkboxes to indicate whether the Authorization for Release of Information was completed or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. The Clinical Supervisor will review the results with the Counselor who is responsible for completing the Authorization for Release of Information to ensure compliance.
3. Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all Clinical Staff
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709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.Client # 2 was admitted on March 22, 2023, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated March 22, 2023, to a funding source and pharmacy did not include a dated signature of the client. Client #2 ' s funder was being billed and medication information was being disclosed as the pharmacy was providing medication. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Project Director will train Clinical Staff in the Electronic Health System to ensure that the client acknowledges and signs all informed and voluntary consents in chart.
2. Furthermore, Nasr Consultant Group has hired a licensed professional counselor to serve as the project's Quality Assurance Specialist. The project has also developed a Quality Assurance Checklist that consists of checkboxes to indicate whether the Authorization for Release of Information was completed or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. The Clinical Supervisor will review the results with the Counselor who is responsible for completing the Authorization for Release of Information to ensure compliance.
3. Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all Clinical Staff
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on six of seven client records reviewed, the facility failed to ensure that there was written acknowledgment by the client that the client had been made aware of their rights at admission in accordance with the facility policy and procedure manual in client record # ' s 1, 2, 4, 5, 6, and 7.Client # 1 was admitted on August 21, 2023, and was still active at the time of the inspection. Client # 2 was admitted on March 22, 2023, and was still active at the time of the inspection. Client # 4 was admitted September 1, 2023, and was still active at the time of the inspection. Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023.Client # 6 was admitted on June 21, 2023, and was discharged on November 3, 2023. Client # 7 was admitted on June 9, 2023, and was discharged on June 25, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train all Clinical Staff to complete the Client's Rights during the Admission Process.
2. Project Director will monitor all Admissions documentation of Client's Rights to ensure that all Clients have been made aware of their and signed the Client's Rights document. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information, client records, personnel records, and the facility policy manual, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.The following materials were requested however the facility was unable to provide them during the licensing process:The Staffing Requirement Facility Summary Report (SRFSR), attestations related to any changes in the policy manual, qualifications for clinical staff, individual personnel training information, and client funding information and counselor caseload information to identify clients on each caseload.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Executive Director will review and inspect the Electronic Heath System for data collection and recordkeeping to ensure that efficient retrieval of Staffing Requirement Facility Summary Report (SRFSR), attestations related to any changes in the policy manual, qualifications for clinical staff, individual personnel training information, and client funding information and counselor caseload information to identify clients on each caseload.
2. The Executive Director will discuss and review with the Project Director all revision made to the Electroic Health System to assure that retrieval of all data collection and recordkeeping needed to measue the project can be retrieve successfully.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on five of five applicable client records reviewed, the facility failed to provide medication, as stated by the facility policy and procedure manual, to be provided as prescribed by a physician and documented by staff by initialing in the appropriate box of the medication log. Also, if medication is refused, the box on the medication log will be circled and occurrence documented on the back of the medication log.Client # 1 was admitted August 21, 2023, and was still active at the time of the inspection. Medications prescribed were not documented as being administered on the following dates: (1) tablet twice daily- August 21, 22, 23, 24, 25, 26, 28, 29, 30, and 31, 2023.(1) tablet daily- August 25, 2023, (1) tablet at bedtime- August 21, 22, 23, 24, and 31, 2023.Client # 2 was admitted March 22, 2023, and was still active at the time of the inspection. Medications prescribed were not documented as being administered on the following dates:(1) tablet two times daily- March 24, 25, 26, 27, 28, 29, 30, and 31, 2023(1) cup two times daily- March 1-31, 2023(1) tablet daily- March 1-31, 2023(1) tablet every eight hours- March 24, 25, 26, 27, 28, and 31, 2023.Client # 3 was admitted September 21, 2023, and was still active at the time of the inspection. Medications prescribed were not documented as being administered on the following dates:(1) tablet two times daily- December 1, 5, 6, 8, 9, 10, 11, 12, 13,14, 15, 16, 17, 18, and 19, 2023.(1) tablet two times daily- December 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,1 6, 17, 18, 19, 2023. Also, when asked to provide the medication bottle for verification, the bottle was unable to be located in the client's medications.(1) tablet Saturdays only- medication was logged to be given every day in December, 2023.(5mg) three times daily- December 1, 2, 3, 4, 5, 6, 7 ,8 ,9, 10, 11, 13, 14, 15, 16, 17, 18, 19, 2023.(2) times daily-Buprenorphine- December 2, 2023.Client # 4 was admitted September 1, 2023, and was still active at the time of the inspection. Medications prescribed were not documented as being administered on the following dates: (100 mg) 8 am dose- December 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 15, 16, 17, 28, 2023.(50mg) two times a day- December 1, 2, 3, 4, 5, 7, 8, 12, 13, 15, 16, 17, 18, 2023.(45mg) bedtime- December 1, 2, 15, 2023.(30 mg) two times daily- December 1, 2, 3 ,4, 5, 7, 8, 11, 12 ,13, 15, 16, 17, 18, 2023.Client # 6 was admitted June 21, 2023, and was discharged November 3, 2023. Medications prescribed were not documented as being administered on the following dates:(1) tablet three times daily- June 22, 24, 25, 26, 37, 28, 29, 30, August 1, 2, 3, 4, 5, 7, 8, 10, 11, 12, 14, 15, 16, 20, 21, 22, 27, 29, 30, 31, 2023.(1) tablet daily- June 24, 25, 27, 2023.(1) tablet daily- August 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 2023.(1) tablet daily- August 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 2023.(1) tablet daily- August 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 26, 29, 30, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Project Director will train all Staff on documentation in the Medication Log of client's taking their medications, refusing medications and medications waiting to be refilled.
2. Project Director will implement a new Medication Log which provides written directions on how to document client's taking, missing, refusing and medications waiting to be refilled.
3. Project Director will train all Staff on the reporting process of Client's refusing to take their medication which is communicating directly to the Project Director.
4. Project Director will monitor the Medication Log on a daily basis. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information and physical plant inspection, the facility failed to inspect storage areas quarterly by a pharmacist consultant and record on a checklist in accordance with the facility policy and procedure manual. There was no documentation that quarterly inventories of the medication room were being completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Policy and Procedure for Quarterly Inspections and Inventories by a license pharmacist was revise and updated by Executive Director to reflect that the Project Director will be responsible for Quarterly Inspections.
2. Inventory Checklist will be created to reflect inventories conducted by Project Director of all medications on a quarterly basis.
3. A Disposal Checklist and Log provided by Medspak Pharmacy has been utilized and conducted on a weekly basis for disposal of medications since 2021. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility ' s unusual incident log, the facility failed to report the Department within 3 business days an unusual incident involving the presence of police, fire or ambulance personnel. An ambulance was documented to be present at the facility on June 22 and July 23, 2023, but was not reported to the Department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director is responsible for submitting Unusual Incident Reports to DDAP Licensing Department.
2. Project Director will submit reports for June 22, 2023 and July 28, 2023 to DDAP Licensing Department.
3. Project Director will ensure that all Unusual Incident Reports are submitted to DDAP Licensing Department within 3 business days as required. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on six of seven applicable client records reviewed, the facility failed to provide intake procedures that included the documentation of the disclosure to the client the criteria for admission, treatment, completion and discharge at admission in accordance with the facility policy and procedure manual in client records # 1, 2, 4, 5, 6, and 7. Client # 1 was admitted on August 21, 2023, and was still active at the time of the inspection. Client # 2 was admitted on March 22, 2023, and was still active at the time of the inspection. Client # 4 was admitted September 21, 2023, and was still active at the time of the inspection. Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023.Client # 6 was admitted on June 21, 2023, and was discharged on November 3, 2023. Client # 7 was admitted on June 9, 2023, and was discharged on June 25, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. A Document was created to review and discuss with all Admissions (Clients) regarding the criteria for admission, treatment, completion and discharge.
2. Clinical Staff will be trained to review and discuss document with Client and obtain Client signature.
3. Project Director will review Client Chart to ensure that the document was reviewed and discussed with Client upon admission. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to have intake procedures that included documentation of client orientation to the project which includes a familiarization with the facility's hours of operation in seven of seven records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Document was created to reflect Client Orientation to Nasr Residential hours of operation.
2. Clinical Staff will review and discuss Nasr Residential hours of operation and obtain Client Signature.
3. Project Director will monitor and review Client Chart to ensure that Client has been made aware of Nasr Residential hours of operation and signed document. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records and the facility's policy manual, the facility failed to have intake procedures that included documentation of client orientation to the project which includes a familiarization with the facility ' s fee schedule, at admission as per facility policy, in seven of seven records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. A Document was created to reflect Client Fees for Service.
2, Clinical Staff will review and discuss Client Fees for Service with Client during the Admission Process and obtain signature.
3. Project Director will review Client Chart to ensure that Client Fees for Service was discussed.
4. A Fee for Service sign was created on 1/27/2024 and placed on wall in Foyer of Nasr Residential. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to include documentation of a physical examination in the intake procedures in six of seven applicable records reviewed.Client # 1 was admitted on August 21, 2023, and was still active at the time of the inspection. There was no physical examination documented in the client record.Client # 2 was admitted on March 22, 2023, and was still active at the time of the inspection. There was no physical examination documented in the client record. Client # 3 was admitted on September 21, 2023, and was still active at the time of the inspection. There was no physical examination documented in the client record.Client # 4 was admitted September 1, 2023, and was still active at the time of the inspection. There was no physical examination documented in the client record.Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023. There was no physical examination documented in the client record.Client # 7 was admitted on June 9, 2023, and was discharged on June 25, 2023. There was no physical examination documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director is responsible for obatining Physical Examinations for all Intakes prior to admission.
2. Project Director will ensure that Physical Examinations are scanned into Client's Chart during their admission. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to include documentation of a psychosocial evaluation within seven days of admission, per facility policy, in three of seven applicable records reviewed.Client # 1 was admitted on August 21, 2023, and was still active at the time of the inspection. There was no documentation of a completed psychosocial evaluation in the record. Client # 3 was admitted on September 21, 2023, and was still active at the time of the inspection. There was no documentation of a completed psychosocial evaluation in the record. Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023. The psychosocial evaluation was due no later than August 28, 2023, but was not completed until September 21, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records to document and complete Biopsychosocial Assessment within 7 days of Client's admission by 2/15/24.
2. Project Direct will review Client Chart within the 7 day time frame to ensure that Biopsychosocial is completed and signed by Counselor.
3. Furthermore, Nasr Consultant Group has hired a licensed professional counselor to serve as the project's Quality Assurance Specialist. The project has also developed a Quality Assurance Checklist that consists of checkboxes to indicate whether the Authorization for Release of Information was completed or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 three of seven applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client within 14 days, per the facility policy. Client # 1 was admitted on August 21, 2023, and was still active at the time of the inspection. There was no documentation of a treatment and rehabilitation plan in the client record.Client # 3 was admitted on September 21, 2023, and was still active at the time of the inspection. There was no documentation of a treatment and rehabilitation plan in the client record.Client # 6 was admitted on June 21, 2023, and was discharged on November 3, 2023. A treatment and rehabilitation plan was due no later than July 5, 2023; however was not completed until July 20, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records to document and complete Preliminary Treatment Plan which reflects the first 14 days of their treatment Process for each client on their caseload.
2. Project Direct review all Client Admissions to ensure that a Preliminary Treatment Plan is Implemented and signed by Client, Counselor and Supervisor.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on three of four applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plan updates at least every thirty days.Client # 2 was admitted on March 22, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was documented on March 22, 2023. A treatment plan update was due to occur no later than April 22, 2023, however, a treatment and rehabilitation plan update did not occur until May 5, 2023.Client # 4 was admitted September 1, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was documented on October 12, 2023. A treatment plan update was due to occur no later than November 12, 2023, however, one was never documented.Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023. A treatment and rehabilitation plan was documented on October 4, 2023. A treatment plan update was due to occur no later than November 4, 2023, however, a treatment and rehabilitation plan update did not occur until December 7, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records to document and complete Comprehensive and Updated Treatment Plans on each client on their caseload every thirty days.
2. Project Direct will conduct bi-weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff remain in compliance with completing Comprehensive and Updated Treatment Plans every 30 days.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 three of four applicable client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.Client # 2 was admitted on March 22, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was documented on March 22, 2023 indicating individual sessions occur one time weekly and educational groups occur three times weekly. A review of progress notes and record of service did not document individual sessions the weeks of March 19-25, April 2-8, May 28-June 3, and September 17-23, 2023.Client # 4 was admitted September 1, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was documented on October 12, 2023 indicating individual sessions occur one time weekly and educational groups occur three times weekly. A review of progress notes and record of service did not document individual sessions the weeks of October 22 through December 16, 2023, or three group sessions the weeks of September 3-9, 10-16, October 1-7, 15-21, November 5-11, 12-18, 19-25, 26- December 2, 10-16, and 17-23, 2023.Client # 6 was admitted on June 21, 2023, and was discharged on November 3, 2023. A treatment and rehabilitation plan was documented on July 20, 2023 and updated August 17 and September 14, 2023, indicating individual sessions occur one time weekly and educational groups occur three times weekly. A review of progress notes and record of service did not document three group sessions the weeks of August 6-12 and October 1-7, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records to document and complete Individual Counseling Sessions on each client on their caseload.
2. Project Direct will conduct bi-weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff are compliance with completing a Individual Counseling Progress Notes for each client on caseload.
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on four of six applicable client records reviewed, the facility failed to provide a complete client record to include progress notes that are reflective of the clients record of service in client records # 3, 4, 5, and 6.Client # 3 was admitted on September 21, 2023, and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on September 25, December 6, and December 13, 2023. There was no completed progress note for those dates in the client record.Client # 4 was admitted September 1, 2023, and was still active at the time of the inspection. A review of the record of service indicates an individual session occurred on October 24 and December 17, 2023, and group sessions on September 8, 11, October 4, 19, 22, and December 11, 18, 2023. There was no completed progress note for those dates in the client record. Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023. A review of the record of service indicates an individual session occurred on November 28, 2023, and group sessions on August 22, 28, September 11, and October 19, 22, 2023. There was no completed progress note for those dates in the client record. Client # 6 was admitted on June 21, 2023, and was discharged on November 3, 2023. A review of the record of service indicates a group session occurred on October 6, 2023. There was no progress note for that date in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records to document and complete all Individual and Group Therapy Progress Notes on each client on their caseload by 2/2/2024
2. Project Direct will conduct bi-weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff are compliance with completing Individual/Group Progress Notes for each client on caseload. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within one week by phone call and documented in client record.Client # 5 was admitted on August 21, 2023, and was discharged on December 7, 2023. There was no follow-up information documented in the client record.Client # 6 was admitted on June 21, 2023, and was discharged on November 3, 2023. There was no follow-up information documented in the client record.Client # 7 was admitted on June 9, 2023, and was discharged on June 25, 2023. There was no follow-up information documented in the client record.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the December 14, 2022 annual licensing inspection.
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Plan of Correction
1. Project Director will train Clinical Staff in the Electronic Health Records to document and complete Follow Up Form on each client on their caseload.
2. Project Direct will conduct bi-weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff are compliance with completing a Follow Up Form for each client on caseload within 7 days of Client's Discharge.
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