INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 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 seven out of seven client records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Naaman Center 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 four out of seven records reviewed.
Client #2 was admitted on December 21, 2021 and was still active at the time of the inspection. A treatment plan was completed on January 26, 2022 and the next update was due no later than March 26, 2022; however, the next update was completed on July 12, 2022.
Client #4 was admitted on April 19, 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 November 11, 2021 and was discharged on May 17, 2022. A treatment plan update was completed on January 4, 2022 and the next update was due no later than March 4, 2022; however, the next update was completed on April 5, 2022.
Client #6 was admitted on March 14, 2019 and was discharged on April 22, 2022. A treatment plan update was completed on January 4, 2022 and the next update was due no later than March 4, 2022; however, the next update was completed on April 5, 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 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)(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 completed within three days of discharge per the facilities policy, in two out of three discharged records reviewed.
Client #5 was admitted on November 1, 2021 and was discharged on May 17, 2022.
Client #6 was admitted on March 14, 2019 and was discharged on April 22, 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 |