INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16, 2025, 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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709.24 (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 client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client #6 was admitted to the residential rehabilitation level of care on October 22, 2024 and discharged against facility advice on November 18, 2024. The facility failed to follow their policy related to against facility advice discharges of calling the emergency contact within twelve hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will retrain all staff to follow the facility's written discharge policy regarding discharges "against facility advice" and to call the emergency contact within twelve hours. 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. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document preliminary treatment and rehabilitation plan, within three days of admission, per facility policy, in two of six applicable records reviewed.
Client #3 was admitted on November 14, 2024 and was still active at the time of the inspection. There was no documentation of a preliminary treatment and rehabilitation plan in the client record.
Client #4 was admitted on October 24, 2024 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due October 27, 2025; however, it was not documented until November 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and Procedure manual has been updated and reads, "Upon completing the biopsychosocial assessment, the counselor will provide a preliminary treatment plan to the client within three (3) days."
Therefore, the counselor will provide the Preliminary treatment plan to the client within three days of completing the biopsychosocial assessment, which is to be completed within seven (7) days of admission.
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. |
709.52(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 a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in four of six applicable records reviewed.
Client #1 was admitted on June 24, 2024 and was still active at the time of the inspection. Client #1` had a treatment and rehabilitation plan developed on July 2, 2024, and the update was due by August 2, 2024; however, it was not completed until August 6, 2024. The following update was completed on August 29, 2024, with the next being due by September 29, 2024; however, it was not completed until October 1, 2024. The next update was due November 1, 2024, but wasn ' t completed until November 10, 2024. The last treatment plan update to be reviewed in the client record was to be completed January 10, 2025; however, there was a blank document in the client record dated January 11, 2025, that had no information entered on the document.
Client #2 was admitted on November 27, 2024 and was still active at the time of the inspection. Client #2 had a treatment and rehabilitation plan developed on December 6, 2024, and the update was due by January 6, 2025; however, there were no additional updates documented in the record.
Client #3 was admitted on November 14, 2024 and was still active at the time of the inspection. Client #3 had a treatment and rehabilitation plan developed on November 27, 2024, and the update was due by December 27, 2025; however, there were no additional updates documented in the record.
Client #4 was admitted on October 24, 2024 and was still active at the time of the inspection. Client #4 had a treatment and rehabilitation plan developed on November 15, 2024, and the update was due December 15, 2024; however, it was not completed until January 1, 2025.
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.
The Facility Director will ensure 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 timely treatment plans are updated. |
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 client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in six of six applicable records reviewed.
Client #1 was admitted on June 24, 2024 and was still active at the time of the inspection. Each of Client #1 ' s treatment and rehabilitation plan and treatment plan updates listed the frequency of individual counseling as once a week. There was no documentation of individual counseling session the week of December 15 - 21, 2024.
Client #2 was admitted on November 27, 2024 and was still active at the time of the inspection. Client #2 ' s treatment and rehabilitation plan dated December 6, 2024, listed the frequency of individual counseling as once a week. There was no documentation of individual counseling session the weeks of December 15 - 21, 2024 or January 5 - 11, 2025.
Client #3 was admitted on November 14, 2024 and was still active at the time of the inspection. Each of Client #3 ' s treatment and rehabilitation plan and treatment plan updates listed the frequency of individual counseling as once a week. There was no documentation of individual counseling sessions the weeks of December 1 - 7, 2024, December 15 - 21, 2024 and January 5-11, 2025.
Client #4 was admitted on October 24, 2024 and was still active at the time of the inspection. Each of Client #4 ' s treatment and rehabilitation plan and treatment plan updates listed the frequency of individual counseling as once a week. There was no documentation of individual counseling sessions the weeks of November 24 - 30, 2024, December 1-7, 2024, and December 15-21, 2024.
Client #5 was admitted on September 21, 2023 and discharge August 7, 2024. Each of Client #5 ' s treatment and rehabilitation plan and treatment plan updates listed the frequency of individual counseling as once a week. There was no documentation of individual counseling sessions the weeks of July 7-13, 2024, July 21-27 had a blank note that only had a date and no information that a session was conducted, and July 28- August 3, 2024, had a blank note that only had a date and no information that a session was conducted.
Client #7 was admitted on August 13, 2024 and discharged on November 18, 2023. Each of Client #7 ' s treatment and rehabilitation plan and treatment plan updates listed the frequency of individual counseling as once a week. There was no documentation of individual counseling sessions the weeks of August 25-31, 2024, September 1-7, 2024, September 15-21, 2024, September 29 - October 5, 2024, had a blank note that only had a date and no information that a session was conducted, and October 20-26, 2024.
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. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, including case consultation notes, once per month, per the facility policy, in four of six applicable records reviewed.
Client #1 was admitted on June 24, 2024 and was still active at the time of the inspection. The only documented case consultation in the record was dated August 1, 2024.
Client #4 was admitted on October 24, 2024 and was still active at the time of the inspection. The record had a case consultation dated November 24, 2024, and the next was to be completed December 24, 2024; however, it was documented on December 25, 2024.
Client #5 was admitted on September 21, 2023 and discharge August 7, 2024. The last documented case consultation was completed on June 20, 2024. There were no additional ones documented up until discharge.
Client #7 was admitted on August 13, 2024 and discharged on November 18, 2023. There was a case consultation dated September 11, 2024, and the next was due November 11, 2024; however, it was not documented until November 14, 2024.
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 to conduct monthly case consultations and complete the case consultation notes. All staff will also 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. |
709.53(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 client records and the facility ' s policy and procedure manual, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, including follow-up information, within thirty days if it is unplanned discharge and within seven days if a planned discharge, per the facility policy, in three of three applicable records reviewed.
Client #5 was admitted on September 21, 2023 and discharge August 7, 2024. There was no documentation of follow-up information in the record.
Client #6 was admitted on October 22, 2024 and discharged November 18, 2024. There was no documentation of follow-up information in the record.
Client #7 was admitted on August 13, 2024 and discharged on November 18, 2023. There was no documentation of follow-up information in the record.
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 to obtain follow-up information from all clients no later than 30 days after discharge. 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. |