INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on June 21, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Nasr Consultant Group, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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.
Client #1 was admitted on January 4, 2024 and was current at the time of inspection. There was not a release of information for the funder. The facility confirmed billing.
Client #2 was admitted on May 9, 2024 and was current at the time of the inspection. There was not a release of information for the funder. The facility confirmed billing.
Client #4 was admitted on April 23, 2024 and was current at the time of the inspection. There was not a release of information for the funder. The facility confirmed billing.
Client #5 was admitted on February 22, 2024 and was discharged on There was not a release of information for the funder. The facility confirmed billing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Before billing, the assigned Counselor obtains the release of information from the Client for the funder.
The Quality Assurance Specialist
will review active client records
weekly utilizing the Quality
Assurance Checklist and will
forward the results to the Director
of Outpatient Programs.
To ensure compliance, the Director of
Outpatient Programs will review
the results with the assigned Counselor who is responsible for completing the
Authorization for Release of
Information form with the Client. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the project failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
Client #1 was admitted on January 4, 2024 and was current at the time of inspection.
Client #2 was admitted on May 9, 2024 and was current at the time of the inspection.
Client #3 was admitted on May 3, 2024 and was current at the time of the inspection.
Client #4 was admitted on April 23, 2024 and was current at the time of the inspection.
Client #5 was admitted on February 22, 2024 and was discharged on
Client #6 was admitted on April 23, 2024 and was current at the time of the inspection.
Client #7 was admitted on June 12, 2024 and was current at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our client rights document in our
electronic health record system has
been updated to include:
"A person receiving care or
treatment under section 7 of the act
(71 P. S. § 1690.107), shall retain
civil rights and liberties except as
provided by statute. No client may
be deprived of a civil right solely
by reason of treatment."
The Quality Assurance Specialist
will review active client records
weekly utilizing the Quality
Assurance Checklist and will
forward the results to the Director
of Outpatient Programs. To ensure
compliance, the Director of
Outpatient Programs will review
the results with the Counselor who
is responsible for checking the
Client's Rights and Responsibilities
with the client. |
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 six out of seven client records, the facility failed to develop a written plan providing for intake and admission which includes a preliminary treatment and rehabilitation plan to be developed in the first session as identified in the manual.
Client #1 was admitted on January 4, 2024 and was current at the time of inspection. The preliminary treatment plan was missing.
Client #2 was admitted on May 9, 2024 and was current at the time of the inspection. The preliminary treatment plan was not done at the first session.
Client #3 was admitted on May 3, 2024 and was current at the time of the inspection. The preliminary treatment plan was not done at the first session.
Client #5 was admitted on February 22, 2024 and was discharged on March 7, 2024. The preliminary treatment plan was not done at the first session.
Client #6 was admitted on April 23, 2024 and was current at the time of the inspection. The preliminary treatment plan was not done at the first session.
Client #7 was admitted on June 12, 2024 and was current at the time of the inspection. The preliminary treatment plan was not done at the first session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our policy and procedure manual
has been updated to include:
"A Preliminary Treatment Plan" will be
included in each client's file within
seven (7) days of the completed
biopsychosocial assessment
(i.e.), within seven (7) days of
admission)."
The Quality Assurance Specialist
will review active client records
weekly utilizing the Quality
Assurance Checklist and will
forward the results to the Director
of Outpatient Programs. To ensure
compliance, the Director of
Outpatient Programs will review
the results with the Counselor who
is responsible for completing the
Preliminary Treatment Plan with
the client. |
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 four of seven client records, the facility failed to assure that counseling services are provided according to the initial treatment and rehabilitation plan.
Client #2 was admitted on May 9, 2024 and was current at the time of the inspection. Client #2 had a treatment and rehabilitation plan dated May 31, 2024, that required an individual session twice a week but only occurred once a week. A review of the progress notes showed one progress note missing for May 30, 2024.
Client #3 was admitted on May 3, 2024 and was current at the time of the inspection. Client #3 had a treatment and rehabilitation plan dated June 7, 2024, that required an individual session once a week but were missing sessions May 31, 2024 and May 24 and June 14, 2024;
Client #4 was admitted April 23, 2024 and was current at the time of the inspection. Client #4 had a treatment and rehabilitation plan dated June 8, 2024, that required an individual session once a week but were missing sessions June 9, 2024; May 20, 2024 and May 5, 2024
Client #6 was admitted April 23, 2024 and was current at the time of the inspection. Client #6 had a treatment and rehabilitation plan dated May 20, 2024, that required an individual session once a week but were missing sessions for June 12,2024, June 7, 2024, June 4, 20224, June 3, 2024 and May 28, 2024
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To provide counseling services
according to treatment plan; the
assigned counselor will complete a
progress note as part of the client
file regardless of if the client shows
or does not show for a scheduled
treatment session.
The Quality Assurance Specialist
will review active client records
weekly utilizing the Quality
Assurance Checklist and will
forward the results to the Director
of Outpatient Programs. To ensure
compliance, the Director of
Outpatient Programs will review
the results with the Counselor who
is responsible for facilitating the
scheduled treatment session with
the client. |