INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on June 9, 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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705.10 (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. Projector Director contacted facility maintenance to install Push Bars at all Exit Doors.
2. Project Director will conduct daily inspection of the facility plant to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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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 a review of five of seven client records, the facility failed to assure that counseling services are provided according to the initial treatment and rehabilitation plan.
Client #1 was admitted on May 9, 2024 and was current at the time of the inspection. Client #1 had a treatment and rehabilitation plan dated May 16, that required an individual session once week. A review of the progress notes showed one progress note missing for May 30, 2024.
Client #2 was admitted on April 17, 2024 and discharged May 5, 2024. Client #2 had a treatment and rehabilitation plan dated April 29, 2024 that showed one progress note missing for April 30, 2024.
Client #4 was admitted on March 4, 2024 and discharged March 19, 2024. Client #4 had a treatment and rehabilitation plan dated March 11, 2024 that required an individual session once a week. A progress notes for March 13, 2024 was incomplete.
Client #5 was admitted on March 12, 2024 and discharged on April 28, 2024. Client #5 had a treatment and rehabilitation plan dated March 20, 2024 that required an individual session once a week. Progress notes for April 11,2024 and April 17, 2024 were blank.
Client #7 was admitted on February 5, 2024 and discharged on April 9, 2024. Client #7 had a treatment and rehabilitation plan dated February 14, 2024 that required an individual session once a week. Progress notes for March 13, 2024, March 20, 2024 and March 25, 2024 were blank.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will facilitate trainings with all Clinical Staff regarding Clinical Documentation of Treatment Plans and how Individual and Progress Notes reflect and confirm services provided.
2. Project Director will train Clinical Staff on completing Treatment Plans, Individual and Group Notes on the day submitted in the Electronic Health System.
3. Project Direct will conduct weekly chart audits and Clinical Staff Meetings to ensure Nasr Residential Clinical Staff are compliance with providing counseling services according to the Treatment Plan for each client on caseload.
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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 a review of three of four applicable client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project which includes follow-up information.
There was no documentation in the client record related to follow up information for the below clients.
Client #2 was admitted on April 17, 2024 and was discharged May 5, 2024.
Client #6 was admitted March 20, 2024 and discharged April 9, 2024.
Client #7 was admitted on February 5, 2024 and discharged on April 9, 2024.
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 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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