INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 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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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 provide documentation of staff being instructed on the use of the fire extinguisher upon employment in two of three applicable records reviewed.
Employee # 3 was hired as a counselor on July 3, 2023, and was still in this position at the time of the inspection. There was no documentation of fire extinguisher training in the personnel record.
Employee # 4 was hired as a counselor on August 4, 2023, and was still in this position at the time of the inspection. There was no documentation of fire extinguisher training in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs 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 Director of Programs will also document this instruction in the employee training attendance record.
In addition, the Director of Programs will review all new hires' personnel charts to ensure they receive fire extinguisher training within the appropriate timeframes.
Lastly, Employee #3 is no longer employed at the outpatient program. However, Employee #4 did complete the fire extinguisher training and it is documented in the employee personnel file.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel on all shifts are trained to perform assigned tasks during emergencies upon employment in three of three applicable records reviewed.
Employee # 2 was hired as a clinical supervisor on August 28, 2023, and was still in this position at the time of the inspection. There was no documentation of training to perform assigned tasks during emergencies in the personnel record.
Employee # 3 was hired as a counselor on July 3, 2023, and was still in this position at the time of the inspection. There was no documentation of training to perform assigned tasks during emergencies in the personnel record.
Employee # 4 was hired as a counselor on August 4, 2023, and was still in this position at the time of the inspection. There was no documentation of training to perform assigned tasks during emergencies in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs will ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies no later than seven (7) days from the date of employment. The Director of Programs will also document this instruction in the employee training attendance record.
In addition, the Director of Programs will review all new hires' personnel charts to ensure they receive emergency training within the appropriate timeframes.
Lastly, Employee #3 is no longer employed at the outpatient program. However, Employee #4 did complete the emergency training and it is documented in the employee personnel file.
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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 ' s policy and procedure manual and discussion with the facility, the facility failed to maintain a current community resource listing of other health and social service agencies. The policy manual indicated the community resource listing is maintained in the manual ' s appendix. During the review of the policy manual appendix there was no community resource list included.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director added a current community resource listing of other health and social service agencies to the appendix of Nasr Consultant Group's Policy and Procedure Manual. Nasr Consultant Group's policy and procedure manual is maintained in the administration office. |
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 administrative documents, 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. Based on a review of the project ' s tax documentation the facility no longer qualifies for the previously approved exception.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of Nasr Consultant Group's tax documentation it was determined Nasr Consultant Group no longer qualifies for the previously approved exception. Therefore, the Executive Director will obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the Nasr Consultant Group's substance use disorder services, following generally accepted accounting principles which include reference to the drug and alcohol treatment activities. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of six applicable records reviewed.
Client # 2 was admitted on August 23, 2023, and was still active at the time of the inspection. The record did not contain an informed and voluntary consent for the funder; however, facility staff confirmed billing was occurring.
Client # 5 was admitted on June 15, 2023, and was discharged September 18, 2023. The record did not contain an informed and voluntary consent for the funder; however, facility staff confirmed billing was occurring.
Client # 7 was admitted on August 29, 2023, and was discharged December 4, 2023. The record did not contain an informed and voluntary consent for the funder; however, facility staff confirmed billing was occurring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs will meet with all staff to direct them to obtain an Authorization for the Release of Information from all clients for the client's funder.
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.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
Lastly, a signed release of information was obtained from Client #2 for the funder. Clients #5 and #7 have been discharged so the facility was unable to obtain a signed release of information.
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709.30 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.
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Observations
Based on a review of client records, the facility failed to ensure documentation of 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 five of seven client records reviewed.
Client # 1 was admitted on August 7, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on August 23, 2023, and was still active at the time of the inspection.
Client # 3 was admitted on September 20, 2023, and was still active at the time of the inspection.
Client # 4 was admitted on April 17, 2023, and was discharged September 18, 2023.
Client # 6 was admitted on March 10, 2023, and was discharged July 19, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs will meet with all staff to direct them to obtain written acknowledgment by clients that they have been notified of client rights.
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 Client's Rights and Responsibilities were reviewed with the client or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and will forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for completing the Client's Rights and Responsibilities.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
Lastly, a signed Client Rights and Responsibilities was obtained from Clients #1, #2, and #3. Clients #4 and #6 have been discharged so the facility was unable to obtain a signed Client Rights and Responsibilities.
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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 provided 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 Electronic Health System to assure that retrieval of all data collection and recordkeeping needed to measure the project can be retrieve successfully.
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709.91(b)(1) LICENSURE Intake and admission
709.91. 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 five of seven client records reviewed, the facility's intake procedures failed to document disclosure to the client of criteria for admission, treatment, completion and discharge in client records # 1, 2, 3, 4, and 6.
Client # 1 was admitted on August 7, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on August 23, 2023, and was still active at the time of the inspection.
Client # 3 was admitted on September 20, 2023, and was still active at the time of the inspection.
Client # 4 was admitted on April 17, 2023, and was discharged September 18, 2023.
Client # 6 was admitted on March 10, 2023, and was discharged July 19, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs will meet with all staff to direct them to review and obtain written acknowledgment from clients that they have been informed of the criteria for admission, treatment, completion, and discharge at admission.
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 Client's Rights and Responsibilities were reviewed with the client or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and will forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for completing the Client's Rights and Responsibilities.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to follow their policies and procedures for client orientation to include documentation of a client orientation to the project with includes a familiarization with the project policies in seven out of seven records reviewed.
The facility ' s policy and procedures for orientation begins at the admission process. During the admission process the client is provided the statement of client rights which provides a familiarization with the project policies. There was no written acknowledgement by the client of the client rights in seven out of seven records reviewed. The project polices are also acknowledged in the preliminary treatment plan which per policy is to be completed in the initial session. The preliminary treatment plans in seven out of seven records were not completed per the policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs will meet with all staff to direct them to review and obtain written acknowledgment from clients that they have been informed of the policies of the project at admission.
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 Client's Rights and Responsibilities were reviewed with the client or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and will forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for completion.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on four of seven client records reviewed, the facility failed to provide intake procedures that include documentation of consent to treatment in client records # 1, 2, 4, and 7.
Client # 1 was admitted on August 7, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on August 23, 2023, and was still active at the time of the inspection.
Client # 4 was admitted on April 17, 2023, and was discharged September 18, 2023.
Client # 7 was admitted on August 29, 2023, and was discharged December 4, 2023.
These findings were reviewed with facility staff during the licensing process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs will meet with all staff to direct them to obtain Consent to Treatment from all clients at admission.
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 Consent to Treatment 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. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for completing the Consent to Treatment.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
Lastly, a signed Consent to Treatment was obtained from Clients #1 and #2. Clients #4 and #7 have been discharged so the facility was unable to obtain a signed Consent to Treatment.
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709.91(b)(7) LICENSURE Intake and admission
709.91. 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 follow their procedures to document preliminary treatment and rehabilitation plans by the end of the first session in seven out of seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Programs will meet with all staff to direct them to complete the preliminary treatment plan for all clients within 7 days of admission.
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 preliminary treatment plan 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. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for completing the Preliminary Treatment Plan.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 a review of client records, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client within fourteen days, per the facility ' s policy, in three of seven client records reviewed.
Client # 1 was admitted on August 7, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was due no later than August 21, 2023, but was not developed until October 19, 2023.
Client # 2 was admitted on August 23, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was due no later than September 6, 2023. The treatment plan was initiated September 5, 2023, signed by the client on October 3, 2023, but was not completed.
Client # 3 was admitted on September 20, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was due no later than October 4, 2023, however, there was no treatment plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our policy states, "The primary counselor meets with client to review the completed psychosocial assessment. Based on the psychosocial assessment a treatment plan is to be completed within 14 days of admission if Intensive Outpatient (IOP) and 21 days of admission if Outpatient (OP).
The Director of Programs will meet with all staff to direct them to complete a comprehensive treatment plan within 14 days of admission if Intensive Outpatient (IOP) and 21 days of admission if Outpatient (OP).
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 Comprehensive Treatment Plan was completed with the client or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and will forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for completing the Comprehensive Treatment Plan.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
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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 review and update the treatment and rehabilitation plans at least every sixty days in four of six applicable records reviewed.
Client # 2 was admitted on August 23, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on October 3, 2023. A treatment and rehabilitation plan update was due no later than December 3, 2023; however, there was no documentation of an update in the client record.
Client # 4 was admitted on April 17, 2023, and was discharged September 18, 2023. A treatment and rehabilitation plan was developed on April 24, 2023. A treatment and rehabilitation plan update was due no later than June 24, 2023, however, it was not completed until July 17, 2023.
Client # 5 was admitted on June 15, 2023, and was discharged September 18, 2023. A treatment and rehabilitation plan was developed on June 20, 2023. A treatment and rehabilitation plan update was due no later than August 20, 2023; however, there was no documentation of an update in the client record.
Client # 6 was admitted on March 10, 2023, and was discharged July 19, 2023. A treatment and rehabilitation plan was developed on March 29, 2023. A treatment and rehabilitation plan update was due no later than May 29, 2023; however, there was no documentation of an update in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 15, 2022, December 20, 2021, October 15, 2020, October 11, 2019, and January 8, 2019, annual licensing inspections.
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Plan of Correction
The Director of Programs will meet with all staff to tell them that treatment plans need to be updated after sixty days for all active clients.
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 Comprehensive Treatment Plan was updated or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and will forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for updating treatment plans.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
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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 client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in five of six applicable records reviewed.
Client # 1 was admitted on August 7, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on August 10, 2023, indicated one individual session a week. A review of the progress notes and record of service only documented individual sessions occurring once in August, twice in September, once in October, and twice in November.
Client # 2 was admitted on August 23, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on October 3, 2023, indicated one individual session a week and three group sessions a week. A review of the progress notes and record of service documented individual sessions occurring weekly in September; however, there were no other individual sessions documented in October or November. Group sessions were documented as occurring once in September, twice in October, and twice in November.
Client # 4 was admitted on April 17, 2023, and was discharged September 18, 2023. A comprehensive treatment and rehabilitation plan developed on April 24, 2023, indicated one individual session a week and three group sessions a week. A review of the progress notes and record of service documented individual sessions only occurring twice in April and none in May, June, July, or August. Group sessions were only documented three times in May and then no other group sessions were documented in June, July or August.
Client # 6 was admitted on March 10, 2023, and was discharged July 19, 2023. A comprehensive treatment and rehabilitation plan developed on March 29, 2023, indicating one individual session a week and three group sessions a week. A review of the progress notes and record of service document individual sessions occurring only twice in April, twice in May, and twice in June. There were no group sessions documented at all during the client ' s time at the facility.
Client # 7 was admitted on August 29, 2023, and was discharged December 4, 2023. A comprehensive treatment and rehabilitation plan developed on September 5, 2023, indicated one individual session a week and three group sessions a week. A review of progress notes and record of service did not document any group sessions occurring.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 15, 2022.
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Plan of Correction
The Director of Programs will meet with all staff to direct them to provide counseling services according to the individual treatment plan.
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 counseling services are being provided according to the individual treatment plan. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and will forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for providing counseling services according to the individual treatment plan.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on three of six applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur quarterly for the first year of services and then annually thereafter.
Client # 4 was admitted on April 17, 2023, and was discharged September 18, 2023. A case consultation was due to occur no later than July 17, 2023; however, one was not documented until August 2, 2023.
Client # 6 was admitted on March 10, 2023, and was discharged July 19, 2023. A case consultation was due to occur no later than June 10, 2023; however, one was not documented in the record.
Client # 7 was admitted on August 29, 2023, and was discharged December 4, 2023. A case consultation was due to occur no later than November 29, 2023; however, one was not documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 15, 2022.
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Plan of Correction
This policy has been updated and restated as "Each client's progress should be reviewed at least quarterly and/or before discharge as a case consultation." The Director of Programs will meet with all staff to direct them to complete a case consultation before discharge or at least quarterly.
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 a case consultation was completed or not. The Quality Assurance Specialist will review active client records weekly utilizing the Quality Assurance Checklist and will forward the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Clinical Supervisor will review the results with the Counselor who is responsible for completing the case consultation.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on three of four 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 # 4 was admitted on April 17, 2023, and was discharged September 18, 2023. There was no follow-up information available in the client record.
Client # 5 was admitted on June 15, 2023, and was discharged September 18, 2023. A follow-up was due no later than September 25, 2023. The follow-up did not occur until October 26, 2023.
Client # 7 was admitted on August 29, 2023, and was discharged December 4, 2023.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 15, 2022, December 20, 2021, October 15, 2020, annual licensing inspections.
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Plan of Correction
This policy has been updated and restated as "Nasr Consultant Group should, within 30 days from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral."
The Director of Programs will meet with all staff to tell them to obtain follow-up information from all clients no later than 30 days after discharge.
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 follow-up was documented or not.
During the bi-weekly meetings, the Director of Programs will obtain a list of discharged clients from that period, if any. The Director of Programs will provide that list to the Administrative Assistant who is responsible for completing the client follow-ups. The Administrative Assistant will complete the client follow-ups for that period. Afterward, the Administrative Assistant will notify the Quality Assurance Specialist that the client file is ready for review. The Quality Assurance Specialist will review the discharged client(s) record 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. To ensure compliance, the Clinical Supervisor will review any incomplete client record with the Counselor who is responsible for a complete client record. The counselor will complete anything outstanding in the client's record. The counselor will review all completions with all staff during the bi-weekly meeting. Finally, the Director of Programs will approve the completed client record.
Additionally, during the bi-weekly staff meeting, the Director of Programs will review the new process with all outpatient staff.
Lastly, a follow-up was documented for Clients #4 and #7.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting treatment and rehabilitation plan updates was submitted and approved by the Department for the December 15, 2022, December 20, 2021, October 15, 2020, October 11, 2019, and January 8, 2019, annual licensing inspection. Completing and documenting treatment and rehabilitation plan updates was again found to be a deficiency in the December 19, 2023, licensing inspection.
A plan of correction for completing and documenting follow-up information in accordance with the facility's policy and procedure manual was submitted and approved by the Department for the December 15, 2022, December 20, 2021, and October 15, 2020. Completing follow-up information was again found to be a deficiency in the December 19, 2023, licensing inspection.
This is a repeat citation from December 15, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our Director of Programs will be responsible for monitoring approved plans of correction. This will be done by the newly hired Quality Assurance Specialist conducting weekly reviews of client records utilizing the Quality Assurance Checklist and forwarding the results to the Director of Programs. The Director of Programs will review the results with the Clinical Supervisor. To ensure compliance, the Director of Programs and the Clinical Supervisor will address non-compliance during bi-weekly staff meetings. |