INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 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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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 a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision for an employee with a high school diploma. Additionally, the facility failed to provide close supervision for at least the first 6 months of employment for an employee with a bachelors degree.
Employee #5 was hired on December 14, 2022 with a high school diploma and was still employed at the time of the inspection. He had no documentation of direct and close supervision.
Employee #6 was hired on March 13, 2023 and was still employed at the time of the inspection. He had no documentation of direct supervision.
This finding was reviewed with the 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. Employee number 5 currently has a bachelor's degree and is receiving direct and close supervision as a counselor assistant. Employee #6 has a bachelor's degree and is receiving direct and close supervision as a counselor assistant. The Clinical Supervisor will work with Lead Counselor to ensure proper supervision and documentation is completed. Executive Director met with Clinical supervisor on 8-15-23 and created plan for staff training and onboarding compliance. Executive director will screen all potential hires to make sure they meet DDAP requirements for Counselor or Counselor Assistant. Clinical Supervisor will keep detailed personnel files containing staff qualifications and trainings. Executive Director and Clinical supervisor will review staff files quarterly for DDAP compliance. Compliance will be met by 8/17/23. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed by the second session with the therapist.
Client #2 was admitted on March 10, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was completed on the fourth session.
Client #6 was admitted on December 20, 2023 and discharged on March 28, 2023. The comprehensive treatment plan was completed on the sixth session.
These findings were reviewed with facility staff during the 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 ensure all comprehensive treatment plans are signed at the 2nd individual counseling session as stated in our Naaman Center policy. Counselors not in compliance will be notified during supervision sessions with the Lead Counselor. Compliance will be met by 8/17/23. |
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 three out of five client records reviewed.
Client #1 was admitted on December 30, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on March 23, 2023 with no type or frequency identified.
Client #2 was admitted on April 28, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 19, 2023 with no type or frequency identified.
Client #6 was admitted on December 20, 2023 and discharged on March 28, 2023. A comprehensive treatment plan was developed on February 21, 2023 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 16, 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 ensure all treatment plans have type and frequency of service clearly documented. Counselors not in compliance will be notified during supervision sessions with the Lead Counselor. Changes have been made to the treatment plan template to assist counselors in entering the type and frequency of service. Compliance will be met by 8/17/23. |
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 six records reviewed.
Client #1 was admitted on December 30, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 23, 2023 and an update was due no later than May 23, 2023; however, it was not completed until June 14, 2023.
Client #3 was admitted on March 13, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 4, 2023 and an update was due no later than June 4, 2023; however, it was not completed until June 21, 2023.
Client #4 was admitted on March 28, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 16, 2023 and the next update was due no later than July 17, 2023; however, none was completed.
Client #7 was admitted on July 21, 2022 and was discharged on June 5, 2023. A treatment plan update was completed on November 15, 2022 and an update was due no later than January 15, 2023; however, it was not completed until February 21, 2023. Additionally, the next update was due no later than April 21, 2023; however, it was not completed until May 9, 2023.
These findings were reviewed with facility staff during the 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. |
709.93(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 case consultation within guidelines established by the facility's policy and procedures manual in six out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 60 days following admission.
Client #1 was admitted on December 30, 2022 and was still active at the time of the inspection. A case consultation was completed on December 30, 2022 and the next one was due March 2, 2023; however, none was completed.
Client #2 was admitted on April 28, 2023 and was still active at the time of the inspection. A case consultation was completed on March 10, 2023 and the next one was due no later than May 10, 2023; however, none was completed.
Client #3 was admitted on March 13, 2023 and was still active at the time of the inspection. A case consultation was completed on March 13, 2023 and the next one was due no later than May 13, 2023; however, it was not completed until June 4, 2023
Client #4 was admitted on March 28, 2023 and was still active at the time of the inspection. A case consultation was completed on March 28, 2023 and the next one was due no later than May 28, 2023; however, none was not completed.
Client #5 was admitted on admitted on September 1, 2022 and was discharged on May 12, 2023. A case consultation was completed on December 6, 2022 and the next one was due no later than February 6, 2022; however, none was completed.
Client #6 was admitted on December 20, 2023 and was discharged on March 28, 2023. A case consultation was completed on December 20, 2023 and the next one was due no later than February 20, 2023; however, none was not completed.
These findings were reviewed with facility staff during the 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 ensure all counselors are following Naaman Center policy of entering case consults at least every 60 days. Counselors not in compliance will be notified during supervision sessions with the Lead Counselor. Compliance will be met by 8/17/23. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan within the guidelines established by the facility's policy and procedure manual in three out of three applicable records. The facility's policy and procedure manual stated the aftercare plan must be completed prior to discharge.
Client #5 was admitted on September 1, 2022 and discharged on May 12, 2023.
Client #6 was admitted on December 20, 2022 and discharged on March 28, 2023.
Client # 7 was admitted on July 21, 2022 and discharged on June 5, 2023.
These findings were reviewed with facility staff during the 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 ensure all discharged charts contain a documented aftercare plan within Naaman Center Policy timeline. Counselors not in compliance will be notified during supervision sessions with the Lead Counselor. Compliance will be met by 8/17/23. |