INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11-12, 2021 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
A review of the fire drill logs was conducted during the onsite inspection for the months of September 2020 through July 2021. The facility failed to conduct unannounced drills in December 2020, January 2021 and February 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed fire drill log on 8/12/21. The Clinical team met on 8/18/21 and the clinical supervisor advised staff of the deficiency and discussed the importance to monthly fire drills. The clinical team on site will continue to do unannounced, monthly fire drills. Simon Dietz, the clinical supervisor, will monitor monthly fire drill chart for compliance. Fire drills will be conducted monthly moving forward. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information in one out of fourteen records reviewed, as there was a form that was missing the purpose of the disclosure.
Client # 3 was admitted on March 1, 2021 and was still active at the time of the inspection. There was a consent to release form dated on March 1, 2021 for a funding source that did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor reviewed clinical chart missing the purpose of disclosure on 8/12/21. The clinical supervisor met with the clinical team on 8/18/21 and discussed the deficiency. The clinical team created a plan to insure that all charts will have the purpose of the disclosure clearly marked. Each counselor will review her own charts to insure that the purpose of disclosure is marked. Chart #3 will be reviewed by primary therapist and clinical supervisor to insure that it is corrected by 9/8/21. Simon Dietz, the clinical supervisor, will monitor consent forms for compliance on a monthly basis. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information in ten out of fourteen records reviewed, as there were forms that were missing a dated signature of the client.
Client # 1 was admitted on December 15, 2020 and was still active at the time of the inspection. There were consent to release forms dated on December 15, 2020 to a lab and funding source. These forms did not include a dated signature of the client.
Client # 2 was admitted on June 22, 2021 and was still active at the time of the inspection. There were consent to release forms dated on June 22, 2021 to a lab, probation and a funding source. These forms did not include a dated signature of the client.
Client # 3 was admitted on March 1, 2021 and was still active at the time of the inspection. There were consent to release forms dated on March 1, 2021 to a lab and a funding source. These forms did not include a dated signature of the client.
Client # 5 was admitted on April 27, 2021 and discharged on July 22, 2021. There was a consent to release form dated on July 13, 2021 for a treatment provider and a consent form dated on July 14, 2021 for a behavioral health facility. These forms did not include a dated signature of the client.
Client # 8 was admitted on November 30, 2020 and discharged on November 30, 2020. There were consent to release forms dated on November 30, 2020 for a lab, probation and an emergency contact. These forms did not include a dated signature of the client.
Client # 9 was admitted on September 28, 2020 and discharged on September 28, 2020. There were consent to release forms dated on September 28, 2020 for a funding source and probation. These forms did not include a dated signature of the client.
Client # 10 was admitted on July 8, 2021 and discharged on July 8, 2021. There were consent to release forms dated on July 8, 2021 for a funding source, a lab and probation. These forms did not include a dated signature of the client.
Client # 12 was admitted on June 1, 2021 and discharged on June 1, 2021. There were consent to release forms dated on June 1, 2021 for a funding source, a lab, a treatment provider and probation. There was also a consent to release form dated June 2, 2021 for a treatment provider. These forms did not include a dated signature of the client.
Client # 13 was admitted on January 21, 2021 and discharged on January 21, 2021. There were consent to release forms dated on January 21, 2021 for probation and a funding source. These forms did not include a dated signature of the client.
Client # 14 was admitted on April 27, 2021 and discharged on April 27, 2021. There were consent to release forms dated on April 27, 2021 for a funding source and probation. These forms did not include a dated signature of the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts missing the client signature on 8/12/21. The clinical supervisor met with the clinical team on 8/18/21 and discussed the deficiency and the need to obtain client signatures on all consents. The clinical team created a plan to insure that all charts will client signatures on the releases. Each counselor will review her own charts to insure that client signatures are present and request clients to come in for an in-person session to sign if they are missing within two weeks of notification. Clients with chart # 1,2, and 3 will be asked by primary therapist to sign all releases before 9/15/21. Clients with chart #5/8/9/10/12/13/ and 14 have already been discharge with verbal consent for releases. They will be required to sign all releases if they re-engage in treatment. Simon Dietz, the clinical supervisor, will monitor consent forms for compliance on a monthly basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two out of seven records reviewed.
Client # 4 was admitted on February 2, 2021 and was still an active client at the time of the inspection.
Client # 6 was admitted on October 28, 2020 and discharged on April 9, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts missing the psychosocial evaluation on 8/12/21. The clinical supervisor met with the clinical team on 8/18/21 and discussed the deficiency. The clinical team created a plan to insure that all charts will have psychosocial completed for each client. Each counselor will review her own charts to insure that the psychosocial is completed. Client with chart #4 will have their psychosocial completed by primary therapist by 9/8/21. Client with chart #6 will have a completed psychosocial if they choose to re-engage in treatment. Simon Dietz, the clinical supervisor, will monitor psychosocial evaluations for completion and compliance on a monthly basis. |