INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on one of four employee personnel records reviewed, the facility failed to provide documentation of six months supervision to include one hour of direct observation for a counselor assistant with a associate ' s degree for employee # 4.
Employee # 4 was hired as a counselor assistant on December 13, 2021 and was still in this position at the time of the inspection. Based on a review of employee # 4's personal record there was no documentation of supervision that included one hour of direct observation with an associate ' s degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with lead counselor on 5/5/22 to discuss direct observation requirements for counselor assistants. The director met with the counselor assistant on 5/25/22 to create a direct observation schedule. The director and/or lead counselor will continue to keep detailed documentation of supervision and direct observation for all counselor assistants.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the facility's fire drill log for the months of October 2021 through May 2022, the facility failed to prepare alternate exit routes to be used during fire drills. All exits documented were in the "back".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with staff on 5/5/22 and reviewed fire drill procedures. At that meeting, staff had already started implementing alternate exit routes during fire drills. The lead counselor will continue to monitor fire drill logs to ensure alternate exits are prepared and marked on log. |
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 seven of seven client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services.
Client # 1 was admitted on October 15, 2021 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on November 1, 2021 however, there was no documentation of type and frequency of services.
Client # 2 was admitted on February 15, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on February 15, 2022 however, there was no documentation of type and frequency of services.
Client # 3 was admitted on March 24, 2022 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 24, 2022 however, there was no documentation of type and frequency of services.
Client # 4 was admitted on October 15, 2021 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on November 11, 2021 however, there was no documentation of type and frequency of services.
Client # 5 was admitted on November 11, 2021 and was discharged April 25, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on January 25, 2022 however, there was no documentation of type and frequency of services.
Client # 6 was admitted on December 7, 2021 and was discharged March 30, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on December 7, 2021 however, there was no documentation of type and frequency of services.
Client # 7 was admitted on January 19, 2022 and was discharged March 21, 2022. A comprehensive treatment and rehabilitation plan was developed with the client on January 19, 2022 however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with Lead counselors on 5/10/22 and reviewed the need to include type and frequency of treatment and rehabilitation services on all treatment plans. The entire clinical team was instructed on 5/11/22 to start including type and frequency of treatment and rehabilitation services on all treatment plans. At this time the treatment plans for all active client were corrected. The Lead counselors and quality assurance analysts will monitor charts to ensure compliance. |
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 two of six applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 2 and # 7.
Client # 2 was admitted on February 15, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 15, 2022. A treatment and rehabilitation plan update was due no later than April 15, 2022 however, a treatment and rehabilitation plan update did not occur until May 4, 2022.
Client # 7 was admitted on January 19, 2022 and was discharged on March 21, 2022. A treatment and rehabilitation plan was developed on January 19, 2022. A treatment and rehabilitation plan update was due no later than March 19, 2022 however, there was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with the Lead counselor to review chart compliance on 5/5/22. The entire clinical team reviewed the requirement to review and update the treatment and rehabilitation plan at least every sixty days. At this time all of the active client treatment plans have been corrected. The lead counselor and quality assurance analysts will monitored charts to ensure compliance.
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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 two of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 7-10 days of discharge.
Client # 6 was admitted on December 7, 2021 and was discharged on March 30, 2022. The discharge summary was due to be completed no later than April 9, 2022 however, the discharge summary was not completed.
Client # 7 was admitted on January 19, 2022 and was discharged on March 21, 2022. The discharge summary was due to be completed no later than March 31, 2022 however, the discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with the Lead counselor to review chart and discharge policy compliance on 5/5/22. The entire clinical team reviewed the requirement to complete a discharge summary within 7-10 days of discharge. The lead counselor and quality assurance analysts will monitor charts to ensure compliance with discharge policy. |