INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 09, 2021 by staff from the 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.
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Plan of Correction
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records in six out of fourteen records reviewed.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021. Client record did not contain documentation of consent to release form to funding source.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020. Client record did not contain documentation of consent to release form to funding source.
Record #7 was admitted on August 17, 2020 and was discharged on March 04,2021. Client record did not contain documentation of consent to release form to funding source.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection. Client record did not contain documentation of consent to release form to funding source.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection. Client record did not contain documentation of consent to release form to funding source.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection. Client record did not contain documentation of consent to release form to funding source.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts missing signatures on 9/15/21. The clinical supervisor met with the primary therapists at this time and reviewed company policy and procedures regarding informed consent and confidentiality. The clinical supervisor created a plan to have all clients sign forms at the next counseling appointment. The therapist will ensure that all active client charts have appropriate signature by 10/15/21.The clinical supervisor, will monitor chart signatures for compliance.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to ensure written acknowledgment that no client may be deprived of a civil right solely by reason of treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute in fourteen of fourteen records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/15/21 the clinical supervisor reviewed the clients rights document and updated it for compliance including client rights according to regulation 709.30. The client rights have been added to the client handbook and this will be reviewed during the initial session with the client and signed for acknowledgment. The therapist will ensure that all active clients review client rights and charts have appropriate signatures by 10/15/21. |
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 a review of the facility fire drill records between August 2020 and July 2021, the facility failed to conduct an unannounced fire drill at least once a month. During the month of October 2020, the facility failed to conduct an unannounced fire drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The clinical supervisor will conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
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 a review of the facility fire drill records between August 2020 and July 2021, the facility failed to prepare alternate exit routes to be used during fire drills. All records reviewed identified rear exit used during all drills.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The clinical supervisor will conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to disclose criteria for admission, treatment completion and discharge in six of fourteen records. Client record did not contain documentation of intake procedure.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record #7 was admitted on August 17, 2020 and was discharged on March 04, 2021.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts that were missing the consent to treat including criteria for admission, treatment completion and discharge, on 9/15/21. The clinical supervisor met with the primary therapists on 9/15/21 and re-trained regarding proper documentation and implementation of the consent to treat forms. The therapist will ensure that all active client have been notified and signed off on acknowledgement by 10/15/21. The clinical supervisor will monitor charts monthly for compliance. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to orientate client to the project policies in six of fourteen records. Client record did not contain documentation of client orientation to the project.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record #7 was admitted on August 17, 2020 and was discharged on March 04, 2021.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/15/21 the clinical supervisor reviewed the orientation process with the primary therapist. The clinical supervisor will ensure that all active clients have been given and acknowledged clinical orientation according to 709.91 by 10/15/21. The clinical supervisor will monitor charts monthly for compliance. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to orientate client to the hours of operation in six of fourteen records. Client record did not contain documentation of hours of operation.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record #7 was admitted on August 17, 2020 and was discharged on March 04, 2021.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/15/21 the clinical supervisor reviewed the orientation process with the primary therapist. The clinical supervisor will ensure that all active clients have been given and acknowledged clinical orientation according to 709.91 by 10/15/21. This orientation will include project policies, hours of operation, fee schedule, and services that are provided. The clinical supervisor will monitor charts monthly for compliance. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to orientate client fee schedule in six of fourteen records. Client record did not contain documentation of fee schedule.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record #7 was admitted on August 17, 2020 and was discharged on March 04, 2021.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/15/21 the clinical supervisor reviewed the orientation process with the primary therapist. The clinical supervisor will ensure that all active clients have been given and acknowledged clinical orientation according to 709.91 by 10/15/21. This orientation will include project policies, hours of operation, fee schedule, and services that are provided. The clinical supervisor will monitor charts monthly for compliance. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to orientate client services provided in six of fourteen records. Client record did not contain documentation of services that could be provided.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record #7 was admitted on August 17, 2020 and was discharged on March 04, 2021.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/15/21 the clinical supervisor reviewed the orientation process with the primary therapist. The clinical supervisor will ensure that all active clients have been given and acknowledged clinical orientation according to 709.91 by 10/15/21. This orientation will include project policies, hours of operation, fee schedule, and services that are provided. The clinical supervisor will monitor charts monthly for compliance. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to have a consent to treatment form completed and signed by client in five of fourteen records. Client record did not contain documentation of consent to treatment.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts that were missing the consent to treat including criteria for admission, treatment completion and discharge, on 9/15/21. The clinical supervisor met with the primary therapists on 9/15/21 and re-trained regarding proper documentation and implementation of the consent to treat forms. The therapist will ensure that all active clients have been notified and signed off on acknowledgement by 10/15/21. The clinical supervisor will monitor charts monthly for compliance. |
709.93(a)(1) 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:
(1) Consent forms.
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Observations
Based on a review of client records, the facility failed to have a consent form signed to funding source in six of fourteen records. At the time of the inspection client record did not contain documentation of consent to release form to funding source.
Record #3 was admitted on December 01, 2019 and was discharged on June 07, 2021.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record #7 was admitted on August 17, 2020 and was discharged on March 04,2021.
Record # 9 was admitted on April 05, 2021 and was an active client as of the date of the inspection.
Record # 10 was admitted on May 26, 2021 and was an active client as of the date of the inspection.
Record # 12 was admitted on February 11, 2021 and was an active client as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts missing signatures on 9/15/21. The clinical supervisor met with the primary therapists at this time and reviewed company policy and procedures regarding informed consent of funding source. The clinical supervisor created a plan to have all clients sign forms at the next counseling appointment. The therapist will ensure that all active client charts have appropriate signature by 10/15/21. The clinical supervisor will monitor chart signatures 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 a review of client records, the facility failed to have a complete client record. Follow up information missing in three of seven records. There was no documentation of follow up at the time of the inspection.
Record #4 was admitted on July 07, 2020 and was discharged on August 28, 2020.
Record #5 was admitted on November 30, 2020 and was discharged on March 04, 2021.
Record #6 was admitted on March 17, 2021 and was discharged on June 29, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts on 9/15/21. The clinical supervisor met with clinical team and administrative staff at this time. The administrative staff will email or mail follow-up letters to all clients within 60 days of discharge in accordance with the Naaman Center follow-up policy. The clinical supervisor will monitor charts monthly for compliance. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #4 and #5 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on October 21, 2019 and was due to have the communicable disease trainings no later than October 21,2020. There was no documentation of HIV/AIDS training and the TB/STD training completion at the date of the inspection.
Employee #5 was hired as a case manager on January 01, 2019 and was due to have the communicable disease trainings no later than January 01, 2021. There was no documentation of HIV/AIDS training and the TB/STD training completion at the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed annual training plan on 9/15/21. The Clinical team met at this time and the clinical supervisor advised staff of the plan to obtain communicable disease trainings per DDAP regulations. The current training plans was reviewed, and staff are on target for current training year. The clinical supervisor will monitor each individual training plan to ensure compliance during 2021 training year. |