INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 2007 through October 16, 2007 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on November 16, 2007.
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Plan of Correction
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a complete drug and alcohol history in four of six records reviewed, # 2, 3, 4 and 6. Drug and alcohol histories were missing information regarding the lengths and patterns of use.
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Plan of Correction
The Clinical Director shall ensure that counselors document lengths and patterns of use in client drug and alcohol histories consistently. A training has been set up for 12/13/07 to address this matter with clinical staff. Clinical Director will provide the training. Subsequent to training, the clinical director will meet with counselors weekly and review a few individual client records with each counselor for the next 3 months and continue addressing deficiencies from State Audit and ensure counselors are documenting appropriately. Each week, the clinical director will review a different set of charts. After the 3 months (by mid-March) of one on one review of client records with individual counselors, the clinical director shall continue with regular quality assurance reviews at least once a month and additional trainings will be scheduled as needed, should there be any deficiencies noted. |
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 in two of four records reviewed, #3 and 5.
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Plan of Correction
The Clinical Director shall ensure that counselors document treatment plan updates consistently. A training has been set up for 12/13/07 to address this matter with clinical staff. Clinical Director will provide the training. Subsequent to training, the clinical director will meet with counselors weekly and review a few individual client records with each counselor for the next 3 months and continue addressing deficiencies from State Audit and ensure counselors are documenting appropriately. Each week, the clinical director will review a different set of charts. After the 3 months (by mid-March) of one on one review of client records with individual counselors, the clinical director shall continue with regular quality assurance reviews at least once a month and additional trainings will be scheduled as needed, should there be any deficiencies noted. |
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 a review of client records, the facility failed to document a complete case consultation in two of three records reviewed, #3 and 4. Case consultations did not include the disposition of the case reviewed.
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Plan of Correction
The Clinical Director shall ensure that counselors document disposition of the case reviewed in case consultations. A training has been set up for 12/13/07 to address this matter with clinical staff. Clinical Director will provide the training. Subsequent to training, the clinical director will meet with counselors weekly and review a few individual client records with each counselor for the next 3 months and continue addressing deficiencies from State Audit and ensure counselors are documenting appropriately. Each week, the clinical director will review a different set of charts. After the 3 months (by mid-March) of one on one review of client records with individual counselors, the clinical director shall continue with regular quality assurance reviews at least once a month and additional trainings will be scheduled as needed, should there be any deficiencies noted. |
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 document follow-up information in three of three records reviewed, #4, 5 and 6.
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Plan of Correction
The Clinical Director shall ensure that counselors document follow-up information consistently. A training has been set up for 12/13/07 to address this matter with clinical staff. Clinical Director will provide the training. Subsequent to training, the clinical director will meet with counselors weekly and review a few individual client records with each counselor for the next 3 months and continue addressing deficiencies from State Audit and ensure counselors are documenting appropriately. Each week, the clinical director will review a different set of charts. After the 3 months (by mid-March) of one on one review of client records with individual counselors, the clinical director shall continue with regular quality assurance reviews at least once a month and additional trainings will be scheduled as needed, should there be any deficiencies noted. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to have the physician sign off on treatment plans on medical assistance clients in six of six records reviewed, #1, 2, 3, 4, 5, and 6.
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Plan of Correction
The Clinical Director shall ensure that physician sign off on treatment plans on medical assistance clients consistently. A training has been set up for 12/13/07 to address this matter with clinical staff and physician. Clinical Director will provide the training. Subsequent to training, the clinical director will conduct regular quality assurance checks to ensure that physician is signing off on treatment plans on medical assistance clients. After 3 months (by mid-March) of regular review of client records, the clinical director shall set up additional training if needed. |