INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2022, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from January-November 2022, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of February 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will facilitate Fire Drill Procedures and Fire Drill Log Documentation Training for all Staff at Nasr Consultants-Residential by January 31, 2023.
2. Project Director will review Fire Drill Log bi weekly to ensure that Fire Drills are being conducted and documented. |
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 and discussion with facility staff, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in two client records reviewed.
Client #2 was admitted on October 18, 2022 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for their funding source documented in the client record, however billing was occurring.
Client #4 was admitted on November 14, 2022 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for their funding source documented in the client record, however billing was occurring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will conduct a Clinical Documentation Training on Informed and Voluntary Consents for all Clinical Staff at NASR Consultants-Residential by January 31, 2023.
2. Project Director will monitor and conduct monthly chart audits on Informed and Voluntary Consents to ensure compliance. |
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 the review of client records, the facility failed to document case consultations within the facility's policy of every 30 days in four out of six applicable records reviewed.
Client #3 was admitted on November 7, 2022 and was still active at the time of the inspection. There was no case consultation documented in the client record.
Client #5 was admitted on July 12, 2022 and discharged on October 21, 2022. A case consultation occurred on July 19, 2022. The next case consultation was due no later than August 19, 2022, and September 19, 2022; however, there was no documentation that any further case consultations were completed
Client #6 was admitted on July 20, 2022 and discharged on September 23, 2022. There were no case consultations documented in the client record.
Client #7 was admitted on March 18, 2022 and discharged on June 10, 2022. There were no case consultations documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will facilitate Clinical Documentation Training on Case Consultations with Clinical Staff by February 6, 2023
2. Project Director will conduct weekly Clinical Team Meetings to ensure that Case Consultations are reviewed and completed every 30 days by February 6,2023.
2. Project Director will conduct Clinical Chart Audit to ensure compliance on a monthly basis. |
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, the facility failed to provide a complete client record that included follow-up information in one out of two applicable records reviewed.
Client #7 was admitted on March 18, 2022 and discharged on June 10, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Project Director will facilitate Clinical Documentation Training on Follow- Up with Clinical Staff by February 6, 2023.
2. Project Director will conduct monthly Chart Audits to ensure and maintain compliance. |