INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 11, 2009 to August 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The 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 September 11, 2009.
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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
Based on the review of fire drill records, the facility failed to document fire drills at least once a month.
The findings include:
The facility's fire drill record was reviewed on August 11, 2009 . The facility failed to document fire drills for the months of November 2008, December 2008, and February 2009.
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Plan of Correction
The Executive Director will see to it that fire drills are conducted at least once each month from this point forward. This issue will be corrected as of 08/31/2009. The Executive Director will designate the Office Manager to conduct this fire drill or they will themselves each month and ensure that it will be done monthly. Office Manager trained in this procedure and will have log set up and monthly reminders in place to be compliant with 705.28. |
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 the review of client records, the facility failed to document case consultation notes in eight of eight client records.
The findings include:
Eight client records were reviewed on August 11, 2009 through August 12, 2009. Case consultations were required in eight records. The facility did not document case consultations in client records #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
Executive Director will see to it that case consultation notes are done according to 709.93. Executive Director will designate the Clinical Supervisor to ensure these notes are completed at least quarterly on clients in treatment. The Clinical Supervisor will meet with the clinical team by 8/31/09 to train and correct this issue. Clinical Supervisor will also randomly review charts on a weekly basis to ensure compliance on this issue. Executive Director will also perform random audits of charts for compliance. |
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 the review of client records, the facility failed to document follow-up as per facility policy in four out of four client records.
The findings include:
Eight client records were reviewed on August 11, 2009 through August 12, 2009. Follow-up was required in four records. The facility did not document client follow-up in #7. Follow-up documented in client records #5, 6, and 8 were two months late as per facility policy. Facility policy states that all referrals will be followed up within one week by phone and all others will be contacted by phone or mail within thirty days. A letter is to be sent at six months.
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Plan of Correction
The Clinical Supervisor will ensure that counselors document follow-up information consistently, and provide clinical training to be compliant by 8/31/09. Executive Director will ensure that office staff, who are responsible for the 30 day and 6 month follow up letters, will mail these in a timely manner. The Executive Director will designate the Office Manager to keep this policy in compliance with appropriate in-house training. A complete list of clients who have been discharged 30 days and 6 months will be sent the appropriate letters, according to Naaman Center's policy. Clinical Supervisor will monitor these follow-up procedures on a monthly basis. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of twelve staff records, the facility failed to document CPR certification in five of five records.
The findings include:
Twelve records were reviewed on August 11, 2009 through August 12, 2009. Five out of five van drivers did not have the required CPR training. The facility did not document CPR certification in records # 8, 9, 10, 11 and 12.
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Plan of Correction
Executive Director will see to it that required CPR certifications are completed for #8,9,10,11,12. This issue will be corrected by 8/31/09. An on site class was already held on 8/17/09 for 8 employees. This issue was only clarified at the audit on 8/11 and 8/12/09. Executive Director and Clinical Supervisor will make sure all required employees are compliant with all required trainings.
In the future, the Executive Director will ensure that all new drivers will have their CPR Certification prior to employment, unless there is another staff certified in CPR and first aid also present during the transport of clients. This training will be held by the American Heart Association or American Red Cross. The Executive Director will ensure all required certifications remain current by keeping a log of when renewals for certification are coming up for drivers and other employees as well. The Executive Director will also schedule these trainings for drivers and other employees as needed. |