INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2023 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(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 two out of four records reviewed.
Client #1 was admitted on January 26, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 13, 2023 and an update was due no later than April 13, 2023; however, it was completed on April 17, 2023. Additionally, the next update was due no later than June 17, 2023; however, none was completed.
Client #2 was admitted on March 27, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 17, 2023 and an update was due no later than June 17, 2023, 2023; however, it was none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 6, 2022 licensing inspection.
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Plan of Correction
The clinical director reviewed audit findings with clinical supervisor and lead counselors on 7-27-23. The Clinical Supervisor and Lead Counselor will review charts to verify compliance and will follow up and train accordingly. All treatment plans will be updated within the 60 day timeframe according to Naaman Center policy. Compliance will be met by 8/17/23. |
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 ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #1 was admitted on January 26, 2023 and was still active at the time of the inspection. The treatment plan dated February 13, 2023 indicated one individual session weekly. There was no documentation of the client received individual therapy between May 2-May 14, May 16-May 27, May 29-June11 and June 11-July 18,2023.
Client #2 was admitted on March 27, 2023 and was still active at the time of the inspection. The treatment plan dated April 17, 2023 indicated bi-weekly individual sessions. There was no documentation that the client received individual sessions between April 18-May 22, and June 14-July18, 2023.
Client #3 was admitted on January 21, 2023 and was still active at the time of the inspection. The treatment plan dated March 22, 2023 indicated individual and group sessions weekly. There was no documentation that the client received group therapy between March 23-July 18, 2023
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director reviewed the audit findings with Clinical Supervisor and Lead Counselors on 7-27-23. The Clinical Supervisor and Lead Counselor will review charts to verify compliance and will follow up and train counselors accordingly. All treatment plans will accurately state the frequency of services being received. If Service frequency is changed, it will be updated in the treatment plan instead of other places in the chart. Compliance will be met by 8/17/23. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical Director reviewed audit Findings with clinical supervisor and lead counselors on 7-27-23. The hour of operation and emergency number were posted on the exterior of the main entrance on 7/27/23 and are visible to the public. Compliance will be met by 8/17/23. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical Director reviewed audit Findings with clinical supervisor and lead counselors on 7-27-23. The hour of operation and emergency number were posted on the exterior of the main entrance on 7/27/23 and are visible to the public. Compliance will be met by 8/17/23. |