INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Naaman Center 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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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #2 was admitted on April 8, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 4, 2022 with no type or frequency identified.
Client #6 was admitted on April 6, 2022 and discharged on July 5, 2022. A comprehensive treatment plan was developed on April 24, 2022 with no type or frequency identified.
Client #7 was admitted on December 2, 2021 and discharged on May 2, 2022. A comprehensive treatment plan was developed on December 30, 2022 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Naaman Center's Treatment Plan Template has been updated by the quality department prior to this inspection. The updated treatment plan header includes type, frequency, and modality. Naaman Center Lead Counselors are in the process of training staff on using the updated treatment plan template and overall treatment plan execution. Staff will be trained by the Lead Counselor in a clinical meeting and reminded in subsequent staff meetings, individual supervision and compliance will be met 11.1.22. |
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 treatment plan updates within the regulatory timeframe in five out of seven records reviewed.
Client #1 was admitted on February 15, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 25, 2022 and the next update was due no later than May 25, 2022; however, the next update was completed on May 31, 2022.
Client #2 was admitted on April 8, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 4, 2022 and the next update was due no later than July 4, 2022; however, the next update was not completed as of time of the inspection.
Client #5 was admitted on March 9, 2022 and was discharged on August 29, 2022. A comprehensive treatment plan was completed on March 14, 2022 and the next update was due no later than May 14, 2022; however, the next update was completed on July 11, 2022.
Client #6 was admitted on April 6, 2022 and was discharged on July 5, 2022. A comprehensive treatment plan was completed on April 21, 2022 and the next update was due no later than June 21, 2022; however, the next update was not completed as of time of the inspection.
Client #7 was admitted on December 2, 2021 and was discharged on May 2, 2022. A comprehensive treatment plan was completed on December 30, 2021 and the next update was due no later than March 2, 2022; however, the next update was completed on April 3, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Lead Counselor will train all clinical staff on timeliness of treatment plan updates, tools to accomplish this, Naaman Center policies and regulations for treatment planning. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.1.22 |
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 the review of client records, the facility failed to document case consultations within the policy and procedure timeframe in five out of seven applicable records reviewed. The facility's policy and procedures manual states all clients will have their treatment reviewed after evaluation and thereafter every sixty days.
Client #2 was admitted on April 8, 2022 and was still active at the time of the inspection. There were no case consultations completed as of the time of the inspection.
Client #4 was admitted on admitted on May 6, 2022 and was still active at the time of the inspection. There was one consultation documented in the client record dated May 6, 2022.
Client #5 was admitted on March 9, 2022 and was discharged on August 29, 2022. There was a case consultation documented in the client record on March 2, 2022 and the next one being due May 9, 2022; however, it was not completed until August 29, 2022.
Client #6 was admitted on April 6, 2022, 2022 and was discharged on July 5, 2022. There was a case consultation documented in the client record on April 6, 2022 and the next one being due no later than June 6, 2022; however, it was not completed until July 2, 2022.
Client #7 was admitted on December 2, 2021 and was discharged on May 2, 2022. There was one case consultation documented in the client record dated December 2, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Lead Counselor will train all clinical staff on the completion and timeliness of case consultations, how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.15.22 |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one out of three discharged records reviewed.
Client #7 was admitted on December 2, 2021 and was discharged on May 2, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will train all clinical staff on the completion and timeliness of Aftercare Plans, how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.8.22 |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of three discharged records reviewed.
Client #5 was admitted on March 9, 2022 and was discharged on June 6, 2022.
Client #7 was admitted on December 2, 2021 and was discharged on May 2, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will train all clinical staff on the completion and timeliness of discharge summaries, how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.8.22 |
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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of one applicable discharged records reviewed.
Client #7 was admitted on December 2, 2021 and was discharged on May 2, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will train all administrative staff who complete follow ups and clinical staff on the completion and timeliness of gathering follow up Information (Follow up contact), how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.8.22 |