INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 2014 by staff from the Division of Drug and Alcohol 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and discussions with the facility director, the facility failed to appoint a project director who met the appropriate experiential qualifications.
The findings include:
Employee # 1 was promoted to project director on 8/25/2014, but does not meet the experiential qualifications for the position. Employee #1 does not have experience in the supervision of others and program planning.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately Employee # 2 will replace Employee # 1 as the project director. That is, employee # 2 is now appointed as the project director for the facility.
Program director will ensure compliance by making no decision to hire until all qualifications for positions are met and verified so that this deficiency does not recur.
The Board of Directors are responsible for oversight. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to ensure that communicable disease training was completed within the required timeframe in one of one personnel records reviewed.
The findings include:
One personnel record which required documentation of mandatory communicable disease training was reviewed during the renewal inspection on 10/15/2014. The facility failed to ensure that TB/STD training was completed within the required timeframe in personnel record # 2.
Employee # 2 was hired on 1/25/2012 as the facility director and primary counselor. This employee was required to obtain 4 hours of TB/STD training by 1/25/2013. Employee # 2 completed the TB/STD training on 9/19/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will ensure that communicable disease training will be completed within the timeframe for all personnel.
This will be done by reviewing all new hires personnel charts to determine if communicable disease training was completed. If completed the Facility Director will document this training in the employee file. If not completed the Facility Director will include the training on the employee's individual training plan.
The Program Director will be responsible for oversight. |
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, the facility failed to document the instruction of staff in the use of fire extinguishers upon employment in one of one personnel records reviewed.
The findings include:
One personnel record requiring the documentation of fire extinguisher training was reviewed during the renewal inspection on 10/15/2014. The facility failed to document the completion of fire extinguisher training upon employment in personnel record # 3.
Employee # 3 was hired on 9/1/2014 as a counselor assistant. Employee # 3 completed the fire extinguisher training on 9/20/2014.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 10/2/2013 inspection.
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Plan of Correction
Facility Director will instruct staff in the use of the fire extinguisher upon staff employment no later than seven (7) days from the date of employment. The Facility Director will also document this instruction in the employee training attendance record.
In addition, the Facility Director will review all new hires personnel charts to ensure they receive fire extinguisher training within the appropriate timeframes. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative records, the facility failed to obtain a written agreement for 24 hour emergency psychiatric and medical coverage.
The findings include:
Administrative records were reviewed for documentation of a service agreement for 24 hour emergency psychiatric and medical coverage. The facility did not have documentation of a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will contact Medical Supervisor by October 31, 2014 to obtain an updated agreement that includes 24-hour emergency psychiatric and medical coverage.
The Facility Director will assure a timely response by Medical Supervisor. (Agreement was received on 11/03/14) |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records, the facility failed to document employee notification of rights in one of one personnel record.
The findings include:
One personnel record requiring documentation of the employee notification of rights was reviewed during the renewal inspection on 10/15/2014. The facility failed to provide documentation of the notification of rights in personnel record # 3.
Employee # 3 was hired as a counselor assistant on 9/1/2014. The personnel record did not contain documentation of the employee being notified of his rights at the time of the review.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Facility Director will document notification of personnel #3's employee rights.
During the initial employee orientation the Facility Director will be responsible for reviewing and documenting notification of employee rights. In addition, Facility Director will file the notification in employee file.
The Program Director will be responsible for oversight. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to demonstrate that all clients were informed of all their rights in ten of ten client records reviewed.
The findings include:
Ten client records requiring documentation of client rights notification were reviewed during the renewal inspection on 10/15/2014. The facility failed to demonstrate that clients # 1 - 10 were informed of the right to inspect their own record, the right to appeal a decision limiting access to their record, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from their record; and the right to submit rebuttal data or memoranda to their own record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Facility Director will include on the Client Rights document the right to inspect their own record, the right to appeal a decision limiting access to their record, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from their record; and the right to submit rebuttal data or memoranda to their own record. The assigned counselor will review the revised Client Rights document with clients
# 1 - 10.
Facility Director will also conduct quality assurance chart audits monthly and outcome reviews will be made with each clinician following the week of the audit.
The Program Director will be responsible for oversight of compliance with the above standards.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in four of six client records reviewed.
The findings include:
Six client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 10/15/2014. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 6, 7 and 9.
Client # 1 was admitted on 4/2/2014 and discharged on 6/12/2014. A comprehensive treatment plan was completed for the client on 4/10/2014. There were no treatment plan updates documented in the client's record.
Client # 6 was admitted on 3/24/2014 and discharged on 7/3/2014. The last treatment plan update for client # 6 was completed on 4/24/2014.
Client # 7 was admitted on 4/4/2014 and discharged on 8/1/2014. A comprehensive treatment plan was completed for the client on 4/9/2014. The subsequent treatment plan update was completed on 6/18/2014.
Client # 9 was admitted on 5/23/2014 and was still an active client at the time of the inspection. A comprehensive treatment plan was completed for the client on 5/30/2014. The subsequent treatment plan update was completed on 8/26/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Facility Director will ensure that treatment plan updates will be completed and/or reviewed within sixty (60) days of initial treatment plan by conducting caseload reviews on a weekly basis in clinical team meeting to monitor this compliance.
Facility Director will also conduct quality assurance chart audits monthly and outcome reviews will be made with each clinician following the week of the audit.
The Program Director will be responsible for oversight of compliance with the above standards. |
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 the review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment plan in seven of ten client records reviewed.
The findings include:
Ten client records were reviewed for the provision of providing counseling services in accordance with treatment plans during the renewal inspection on 10/15/2014. The facility failed to ensure that clients received counseling services according to the client's individual treatment plan in client records # 1, 3, 4, 6, 7, 8 and 9.
Client record # 1 contained a treatment plan dated 4/10/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the week of 5/12/2014 - 5/16/2014.
Client record # 3 contained a treatment plan dated 6/19/2014 that identified the counseling services to be provided as individual sessions two times per week. The record did not contain documentation of any individual sessions during the weeks of 7/21/2014 - 7/25/2014 and 7/28/2014 - 8/1/2014. Furthermore, the client only received one individual session during the weeks of 8/4/2014 - 8/8/2014 and 8/11/2014 - 8/15/2014.
Client record # 4 contained a treatment plan dated 5/19/2014 that identified the counseling services to be provided as individual sessions two times per week and a group session one time per week. The record did not contain documentation of any group sessions during the week of 7/7/2014 - 7/11/2014. Furthermore, the client only received one individual session during the weeks of 7/7/2014 -7/11/2014 and 7/14/2014 - 7/18/2014.
Client record # 6 contained a treatment plan dated 3/28/2014 that identified the counseling services to be provided as individual sessions two times per week and a group session one time per week. The record did not contain documentation of any individual and group sessions during the weeks of 5/26/2014 - 5/30/2014, 6/2/2014 - 6/6/2014 and 6/16/2014 - 6/20/2014.
Client record # 7 contained a treatment plan dated 4/9/2014 that identified the counseling services to be provided as an individual session one time per week and a group session one time per week. The record did not contain documentation of any individual and group sessions during the weeks of 6/30/2014 - 7/4/2014 and 7/21/2014 - 7/25/2014.
Client record # 8 contained a treatment plan dated 7/7/2014 that identified the counseling services to be provided as individual sessions two times per week and a group session one time per week. The record did not contain documentation of any group sessions during the weeks of 9/8/2014 - 9/12/2014 and 9/29/2014 - 10/3/2014. Furthermore, the client only received one individual session during the weeks of 9/8/2014 - 9/12/2014, 9/15/2014 - 9/19/2014, 9/22/2014 - 9/26/2014 and 9/29/2014 - 10/3/2014.
Client record # 9 contained a treatment plan dated 5/30/2014 that identified the counseling services to be provided as an individual session one time per week. The record did not contain documentation of any individual sessions during the weeks of 9/1/2014 - 9/5/2014, 9/8/2014 - 9/12/2014, 9/22/2014 - 9/26/2014 and 9/29/2014 - 10/3/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, counselors will ensure that counseling services are provided according to the individual treatment plan.
This will include documenting when a client reschedules or fails to show for any scheduled individual/group session.
The Facility Director will conduct caseload reviews on a weekly basis in clinical team meeting to monitor this compliance.
Quality assurance chart audits will also be conducted monthly and outcome reviews will be made with each clinician following the week of the quality assurance meeting.
The Program Director will be responsible for oversight of compliance with the above standards. |
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 the review of client records, the facility failed to ensure that a complete record was documented in six of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 10/15/2014. The facility failed to document a complete record of service in client records # 1, 2, 5, 6, 7 and 8.
Client # 1 was admitted on 3/24/2014 and discharged on 6/12/2014. The record of service for the client did not include the individual counseling session that the client attended on 6/12/2014.
Client # 2 was admitted on 6/30/2014 and discharged on 8/14/2014. The record of service for the client did not include the group counseling sessions that the client attended on 7/2/2014, 7/9/2014, 7/16/2014, 7/23/2014, 7/30/2014, 8/6/2014 and 8/13/2014.
Client # 5 was admitted on 6/5/2014 and discharged on 8/6/2014. The record of service for the client did not include the group counseling sessions that the client attended on 6/11/2014, 6/18/2014, 6/25/2014, 7/2/2014, 7/9/2014, 7/16/2014, 7/23/2014 and 7/30/2014.
Client # 6 was admitted on 3/24/2014 and discharged on 7/3/2014. The record of service for the client did not include the group counseling sessions that the client attended on 3/29/2014, 4/5/2014, 4/12/2014 and 5/3/2014.
Client # 7 was admitted on 4/4/2014 and discharged on 8/1/2014. The record of service for the client did not include the group counseling sessions that the client attended on 4/19/2014, 4/26/2014, 5/28/2014, 6/4/2014, 6/11/2014, 6/18/2014, 6/25/2014, 7/9/2014 and 7/16/2014.
Client # 8 was admitted on 5/30/2014 and was still an active client at the time of the inspection. The record of service for the client did not include the group counseling sessions that the client attended on 9/3/2014, 9/17/2014, 9/24/2014 and 10/8/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the following clinical documents will be completed and filed in each client record according to the listed time frames:
Client # 1: The individual counseling session that the client attended on 6/12/2014 will be documented on record of service in the client's file by the assigned counselor.
Client # 2: The group counseling sessions that the client attended on 7/2/2014, 7/9/2014, 7/16/2014, 7/23/2014, 7/30/2014, 8/6/2014 and 8/13/2014 will be included the client's record of service by the assigned counselor.
Client # 5: The group counseling sessions that the client attended on 6/11/2014, 6/18/2014, 6/25/2014, 7/2/2014, 7/9/2014, 7/16/2014, 7/23/2014 and 7/30/2014 will be included the client's record of service by the assigned counselor.
Client # 6: The group counseling sessions that the client attended on 3/29/2014, 4/5/2014, 4/12/2014 and 5/3/2014 will be included the client's record of service by the assigned counselor.
Client # 7: The group counseling sessions that the client attended on 4/19/2014, 4/26/2014, 5/28/2014, 6/4/2014, 6/11/2014, 6/18/2014, 6/25/2014, 7/9/2014 and 7/16/2014 will be included the client's record of service by the assigned counselor.
Client # 8: The group counseling sessions that the client attended on 9/3/2014, 9/17/2014, 9/24/2014 and 10/8/2014 will be included the client's record of service by the assigned counselor.
The facility director will conduct caseload reviews on a weekly basis in clinical team meeting to monitor this compliance.
Quality assurance chart audits will also be conducted monthly and outcome reviews will be made with each clinician following the week of the quality assurance audits.
The Program Director will be responsible for oversight of compliance with the above standards.
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