INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2019 of NASR Consultant Group Inc by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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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 and conversation with facility staff, the facility failed to provide documentation of direct observation and close supervision for counselor assistants by a trained counselor or clinical supervisor in two of two records reviewed. Employee #3 was hired on April 1, 2018 as a counselor assistant with a high school diploma. The facility was required to provide direct observation through July 1, 2018 and close supervision through April 1, 2019. The facility was unable to provide documentation of supervision after June 22, 2018. Employee #4 hired on October 1, 2018 as a counselor assistant with a high school diploma. The facility was required to document direct observation through January 1, 2019 and close supervision through October 1, 2019. The facility was unable to provide documentation of any direct observation or close supervision since the employee ' s hire date. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nasr Consultant Group will be more diligent and thorough during the supervised period of a counselor assistant with a high school diploma. Effective immediately, the Lead Counselor will provide direct and close supervision for Employee #3. Employee #4 is no longer on Nasr Consultant Group's employee roster. Furthermore, the Facility Director will ensure the direct observation and the close supervision is documented by the Lead Counselor. This will be done by reviewing the documentation of the direct observation and/or close supervision with the Lead Counselor on a bi-weekly basis. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of counselor assistants working toward counselor status in two of two records. Employees #3 and #4 are employed as counselor assistants, but there personnel records did not include documentation that they are working towards counselor status. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nasr Consultant Group is now in compliance with 704.10. Promotion of counselor assistant. Employee #3 provided a letter to the Facility Director that documents work toward counselor status which includes enrollment in a human services program leading to a degree. Employee #4 is no longer on Nasr Consultant Group's employee roster. The Facility Director will monitor and ensure Nasr Consultant Group remains in compliance with 704.10 Promotion of a counselor assistant by requiring new hires for the position of counselor assistant to provide a letter to the Facility Director that documents work toward counselor status. The documentation will be obtained at the end of each calendar year. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility's training records, the facility failed to provide documentation of feedback on completed trainings. No feedback forms were presented at the time of inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nasr Consultant Group has revised the training evaluation form. The Facility Director made copies available to all staff and required that all staff complete the training evaluation form upon completion of all training moving forward. Additionally, all staff are required to complete the training evaluation form for all completed training during the year 2018 by February 19, 2019. The Facility Director will monitor and ensure Nasr Consultant Group remains in compliance with 704.11 (a)(3) Training feedback by requiring staff to submit a training evaluation form to the Facility Director no later than a week after a completed training. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records for newly hired staff, the facility failed to document instruction in fire extinguisher training upon employment, in two of two records reviewed, specifically employees #3 and #4.Employee # 3 was hired on April 1, 2018. There was no documentation of training on the use of the fire extinguisher in the employee record as of the date of the licensure inspection, January 8, 2019. Employee # 4 was hired on October 1, 2018. There was no documentation of training on the use of the fire extinguisher in the employee record as of the date of the licensure inspection, January 8, 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director did instruct Employee #3 in the use of the fire extinguisher on 02/12/2019. The Facility Director did document this instruction in the employee training attendance record. Employee #4 is no longer on Nasr Consultant Group's employee roster. Facility Director will instruct staff in the use of the fire extinguisher upon employment. The Facility Director will also document this instruction in the employee training attendance record. Additionally, the Facility Director will monitor and review all new hires personnel charts to ensure they receive fire extinguisher training within the appropriate time frames for compliance with 705.28 (c) (4).
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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 a review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed, #2, and #3.Client #2 was admitted on October 10, 2018 and was still an active client at the time of the inspection. There was documentation that a report was made to the Medical Assistance Transportation Program (MATP) on October 26, 2018; however, there was no consent to release information form signed by the client prior to disclosure.Client #3 was admitted on April 9, 2018 and was still an active client at the time of the inspection. There was documentation that a report was made to the Medical Assistance Transportation Program (MATP) on April 26, 2018; however, there was no consent to release information form signed by the client prior to disclosure.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director met with all staff to direct them to obtain a release of information to the Medical Assistance Transportation Program from all clients when correspondence is necessary. A signed release of information to the Medical Assistance Transportation Program was obtained for Client #2 on 02/07/2019. Client #3 has been discharged so facility was unable to obtain a signed release of information to the Medical Assistance Transportation Program. The Facility Director will review active client records weekly and provide increased feedback as necessary. Additionally, the Facility Director will review with counselors during the bi-weekly staff meetings for compliance.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four of seven client records reviewed.Client #1 was admitted on October 15, 2018 and was still an active client at the time of the inspection. A treatment plan update was completed on November 5, 2018 and the next update was due no later than January 5, 2019; however, there was no update documented in the record at the time of the inspection. Client #2 was admitted on October 10, 2018 and was still active at the time of the inspection. A preliminary treatment plan was completed on 10/10/18. There were no updates documented in the record at the time of the inspection. Client #3 was admitted on April 9, 2018 and was still an active client at the time of the inspection. A treatment plan update was completed on May 31, 2018 and the next update was due no later than July 30, 2018; however, there were no additional updates documented in the record at the time of the inspection.Client #4 was admitted on July 19, 2018 and was discharged on October 16, 2018. A treatment plan was completed on July 20, 2018 and the next update was due no later than September 20, 2018; however, the treatment plan was not updated until October 9, 2018. These findings were reviewed with 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, treatment plans and treatment plan updates was documented in client records #1, #2, #3, and #4. These corrective actions were completed on 02/16/2019. Counselors will provide a list of their active clients to the Facility Director bi-weekly. The Facility Director will review active client records weekly and provide increased feedback to Counselors as necessary. Additionally, the Facility Director will review with counselors during the bi-weekly staff meetings for compliance with 709.92 (b). |
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 seven outpatient client records, the facility failed to document counseling services provided according to the individual comprehensive treatment plan in five of seven records reviewed.Client #1 was admitted on October 15, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan, dated November 5, 2018, stated one group sessions per week. The record of services and progress notes indicated client #1 did not receive any group sessions.Client #4 was admitted on July 19, 2018 and was discharged October 16, 2018. The treatment plan, dated July 20, 2018, stated two individual session per week. The record of services and progress notes indicated client #4 only received one individual session per week between July 20, 2018 through October 16, 2018. Client #5 was admitted on September 27, 2018 and was discharged December 27, 2018. The treatment plan, dated October 25, 2018, stated one group session per week and one individual session per week. The record of services and progress notes indicated client #5 did not receive an individual session between October 4, 2018 through October 31, 2018 and received no group sessions between November 21, 2018 and December 7, 2018. Client #6 was admitted on March 16, 2018 and was discharged May 2, 2018. The treatment plan, dated March 30, 2018, stated one group session and one individual session per week. The record of services and progress notes indicated client #6 did not receive any group sessions between March 22, 2018 through May 2, 2018. Client #7 was admitted on September 6, 2018 and was discharged October 3, 2018. The treatment plan, dated September 6, 2018, stated one group session and one individual session per week. The record of services and progress notes indicated client #7 did not receive any group sessions between September 13, 2018 through October 3, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nasr Consultant Group will assure that counseling services are provided according to individual treatment and rehabilitation plan. In order to achieve compliance with 709.92 (C), Counselors will hold the clients on their caseload accountable for attending their scheduled sessions. When clients are not showing up for their scheduled sessions the counselor will document it on the client's Record of Service form and contact the client. If a client's attendance becomes problematic consequences may include a behavioral contract or involuntary discharge. Clients will be informed of these potential consequences by their counselor during intake and admission process. |
709.93(a) 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:
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include client-related correspondences, progress notes discharge summaries, and follow-up information in client record #'s 1, 2, 3, 4, 5, 6, and 7.Client #1 was admitted on October 15, 2018 and was still an active client at the time of the inspection. The client record did not contain documentation of progress notes and client related correspondences. Client #2 was admitted on October 10, 2018 and was still an active client at the time of the inspection. The client record did not contain documentation of progress notes. Client #3 was admitted on April 9, 2018 and was still an active client at the time of the inspection. The client record did not contain documentation of progress notes and client related correspondences. Client #4 was admitted on July 19, 2018 and was discharged on 10/16/18. The client record did not contain documentation of progress notes, client related correspondences, discharge summary and follow up information.Client #5 was admitted on September 27, 2018 and was discharged on December 27, 2018. The client record did not contain documentation of a discharge summary. Client #6 was admitted on March 16, 2018 and was discharged on May 2, 2018. The client record did not contain documentation of discharge summary and follow up information.Client #7 was admitted on September 6, 2018 and was discharged on October 3, 2018. The client record did not contain documentation of client related correspondences, discharge summary and follow up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to resolve the issue of providing a complete client record; discharge summaries and follow-up information were completed as relative and needed in client records #1, #2, #3, #4, #5, #6, and #7. These corrective actions were completed on 02/16/2019. Further, in order to resolve this issue involving progress notes, discharge summaries, and follow up information; Counselors will provide a list of their active clients to the Facility Director bi-weekly. The Facility Director will review active client records weekly and provide increased feedback to Counselors as necessary. Additionally, the Facility Director will review with counselors during the bi-weekly staff meetings for compliance with 709.93 (a). |