INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20-21, 2013, 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.
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the residential facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The findings include:
A physical plant inspection was conducted on August 21, 2013. During the physical plant inspection there were two areas on the ceiling in the staff break room that had water damage and black mold.
This finding was confirmed by the facility director and was not disputed.
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Plan of Correction
Project Director has already contacted a professional to come and repair the small, kitchen ceiling area that had water damage from a previous storm. This area will be treated for any mold residue found and repainted. Project Director will ensure its completion by 10/31/2013 to be in compliance with physical plant regulations.
Project Director contracted a builder to replace and/or repair attic window to prevent future inside water damage. Project will be completed by 10/31/13. Periodic inspection of outside windows will occur by the Project Director to insure this deficiency does not recur. Facility to be in full compliance by 10/31/2013. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
The physical plant inspection took place on August 21, 2013. The licensing specialist was completing an initial inspection of newly renovated counseling space. The space had two doors with windows and three windows that did not have window coverings.
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Plan of Correction
This renovated space is not being utilized to see clients until final approval received from Licensing. Occupancy and Zoning Permits already received. Facility intends to be in full compliance prior to seeing clients in October. Two doors will have the window treatments and the three windows will have coverings in place as well. Pictures will be emailed to Licensing for approval. Project Director will ensure window coverings for this newly renovated counseling space are in place by 9/18/2013 to be in compliance with physical plant regulations.
Project Director will inspect this building periodically to insure that window coverings will remain in place at all times so this deficiency will not recur. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility director's office included a heater that was not permanently mounted or installed.
The findings include:
On August 20, 2013 the director's office included a heater that was not permanently mounted or installed. The space heater was observed by the two licensing specialists who conducted the inspection.
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Plan of Correction
Project Director immediately removed the heater that was not permanently mounted or installed on the day of the audit. The intent was to mount it on the wall, however, it was not an acceptable mount. To be in full compliance, facility will have no heaters that are not permanently mounted or installed on the premises, effective immediately. Project Director will re-train staff at quarterly meeting scheduled for 9/18/2013 as to this regulation and will monitor routinely for full compliance. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on observation during the physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail.
The findings include:
The physical plant inspection took place on August 21, 2013. At approximately 2:50 p.m. the exterior building that was recently renovated for office space was toured. There were four exterior steps that did not have a well-secured handrail in place. Additionally, there were a set of stairs leading to an attic that exceeded two steps and did not have a well-secured handrail.
The finding was discussed with the facility director.
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Plan of Correction
Project Director has contacted a professional to install two handrails for the following: 1) steps down to an outside storage area of the newly renovated building, and 2) steps to the attic in the main building. The attic is sealed off and no clients or staff go in this area, however, to be in full compliance a handrail will be installed by 10/15/2013 in both places. Project Director will ensure completion of both projects to maintain and secure these areas. Facility intends to comply with all physical plant regulations. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection, the facility failed to provide smoke detectors in the attic.
The findings include:
Based on a physical inspection on August 21, 2013, the facility did not have a smoke detector in the attic, as required.
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Plan of Correction
Facility intends to fully comply with physical plant regulations. The attic gets very hot and has an operable heat detector currently. Project Director is filing for an Exception regarding having a smoke detector that may give false alarms due to cob webs, spiders, etc. However, if the Exception is not granted, facility will comply by maintaining a smoke detector in the attic by 10/31/2013. |
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 fire drill record log, the facility failed to document monthly fire drills.
The findings include:
The fire drill record log was reviewed on August 20, 2013. The log was reviewed from August 2012 to July 2013. There was no fire drill documented for October 2012.
The facility director confirmed the findings.
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Plan of Correction
Office Manager will ensure that fire drills will be conducted at least once a month, on different days of the week that clients are seen, at different times of the day, utilizing different staff to ensure procedures are familiar to both staff and clients and be in compliance. Project Director will review this process with Office Manager by 9/12/2013 and perform random checks of the fire drill logs for ongoing compliance. Facility to be in full compliance by 9/30/2013. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in two of seven patient records reviewed.
The findings included:
Seven patient records were reviewed August 20-21, 2013. Seven records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in two patient records reviewed, # 4 and 5.
A review of patient record # 4 revealed information was released to a funding source on January 8, 2013. The patient did not sign a release prior to releasing information for the funding entity.
A review of patient record # 5 revealed information was released to a funding source on December 18, 2012 and February 6, 2013. The patient did not sign a release prior to releasing information for the funding entity.
The findings were confirmed by the facility director.
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Plan of Correction
Informed and voluntary consent forms will be obtained for all clients prior to releasing any information. Office and clinical staff will be re-trained regarding the mandatory use of consents when sending information to funding sources. All staff will be re-trained at the quarterly staff meeting on 9/18/2013. The Office manager will be responsible for office staff compliance. Clinical Director will be responsible for clinical staff compliance. Ongoing supervision will occur for compliance by Office Manager and Clinical Director. Facility to be in full compliance by 9/30/2013. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records, the facility failed to verify that the individual has reached the age of 18 prior to the administration of a narcotic agent, specifically Suboxone in five of five records reviewed.
The findings include:
Five patient records were reviewed August 20-21, 2013. All patient records were reviewed for documentation of verification that the individual had reached 18 years of age. The facility failed to document the verification of age in all records reviewed, # 1 2, 3, 4 and 5. Additionally, patient #3 had not reached the age of 18.
Patient # 3 was admitted on April 8, 2013 and was 16 years old. The patient received their first prescription of Suboxone on April 11, 2013. They did not meet the eligibility requirements.
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Plan of Correction
Office Manager has already trained staff that all clients must have a picture ID, effective immediately. An all-staff meeting is scheduled for 9/18/2013. Office Manager and Clinical Director will re-train office staff to take a digital picture, print, date, and file in client's chart. Another form of ID that identifies client's date of birth to verify age will be copied and filed in chart to be in compliance with this regulation. No one under the age of 18 will be prescribed Suboxone unless an Exception has been submitted by the Medical Director and approved by Licensing.
16 year-old client that was in treatment is no longer in treatment because client stopped attending and did not reply to the 10-day letter sent 8/12/2013, part of facility policy and procedure process. Client discharged on 8/26/2013 as facility was unable to contact client. No adolescents will be admitted to the Suboxone program to be in full compliance with licensing regulations.
Office Manager, Clinical Director and Project Director will work together for ongoing compliance by providing random chart reviews. Facility to be in full compliance by 9/18/2013
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to the administration of an agent in five of five patient records reviewed.
The findings include:
Five patient records were reviewed on August 20-21, 2013. Eight patient records were specifically reviewed for patient identity information. Patient records # 1, 2, 3, 4 and 5 did not contain documentation that verified the patient's identity prior to the administration of an agent.
This finding was discussed with the facility director and the clinical supervisor and was not disputed.
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Plan of Correction
Office Manager will be responsible to train office staff to insure that a client's identity is verified by taking a digital picture of client, print, date and file in client's chart. Office staff will also obtain and copy verification of client's name, address, date of birth, and other identifying data and put in client's chart prior to the prescribing of a narcotic agent. Office staff will verify this information is in chart prior to Medical Director seeing client for their appointment. Office Manager and Clinical Director will re-train all office staff at the quarterly all-staff meeting on 9/18/2013 to insure ongoing compliance. Clinical Director will work with Office Manager and Project Director to ensure compliance by also providing random chart reviews. Facility to be in full compliance by 9/18/2013. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document pre-natal support in one of one patient record reviewed.
The findings include:
One patient record was reviewed for documentation of prenatal support on August 21, 2013. Patient record # 4 was required to reflect the nature of prenatal support that was being provided. The record contained documentation that the patient had a midwife and obstetrician, however, there were no consent to releases signed by the patient to coordinate care for these services. There was no evidence in the record that the facility confirmed prenatal care was being provided for this patient.
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Plan of Correction
Pre-natal cupport will be documented in client's chart to include consent to release, signed by client, for midwife and/or obstetrician and the hospital selected for the birth, to provide coordination of care for the pregnancy. Confirmation of prenatal care being provided will be included in the chart documentation by Medical Director and/or staff. Suboxone contract and consent will be revised to include the above procedures. Clinical Director will perform random chart audits to ensure ongoing compliance. All staff will be trained according to these procedures at the all-staff quarterly meeting on 9/18/2013. Facility to be in full compliance by 9/30/2013. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review patient records, the facility failed to fully inform each female patient of the possible risk to her and her unborn child of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program in three of five patient records.
The findings include:
Five patient records were reviewed on August 20-21, 2013. Three of the patients were females and the program was required to inform each female of the possible risk to her and her unborn child of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program.
The informed patient consent forms contained in the three female patient records, # 3, 4 and 5 failed to include the above mentioned information.
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Plan of Correction
All female clients will be fully informed of the possible risk to her and her unborn child of continued use of illicit dugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program by the Medical Director. Clients have been informed verbally in the past, however, Suboxone policy and procedures have already been revised by the Clinical Director to include the above information for clarity and to be in compliance of Licensing regulations. Suboxone contract and consent forms have also been revised to fully inform female clients of risks associated with the use of Suboxone. All staff will be trained by the Clinical Director regarding this regulation at the staff meeting on 9/18/2013. Clinical Director and Project Director will work together and perform random chart audits to ensure compliance of all required documentation pertaining to female Suboxone clients being informed of risks to this narcotic. Facility to be in full compliance by 9/12/2013. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the review of patient records and staff interviews, the facility failed to have a system for maintaining an onsite photographs of each patient for the purpose of verifying the correct identity of a patient prior to administration of an agent.
The findings include:
Five patient records were reviewed on August 20-21, 2013. All records were reviewed for documentation of patient identification for the purpose of verifying the patient's identity prior to the administration of an agent. Patient records # 1, 2, 3, 4 and 5 failed to include documentation of patient identification in the the record.
This finding was reviewed with the facility director and clinical supervisor and was not disputed.
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Plan of Correction
Office Manager will implement immeditaely that digital photo ID's are taken by office staff for each client for the purpose of verifying the correct identity of a client prior to administration of an agent. Staff will print, date and file pictures in client's chart. The date reflecting when the picture was taken by the facility will assist staff to know when to update the photo if the client remains in treatment for three years. Staff will be re-trained regarding these procedures on 9/18/2013 by the Office Manager. Clinical Director and Office Manager will work together to perform random chart audits for compliance. Ongoing supervision will be provided by Office Manager. Facility to be in full compliance by 9/18/2013. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. Additionally, the facility failed to ensure random monthly urinalysis for each patient.
The findings include:
Five patient records were reviewed on August 20-21, 2013. All patient records were required to complete a drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. All patient records were required to have random monthly urinalysis. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent in five of five records, # 1, 2, 3, 4, and 5. The facility failed to document a random monthly urinalysis in three of five patient records # 1, 2 and 4.
Patient # 1 was admitted on 4/15/2013 and received their first dose of Subutex on 5/7/2013. The patient provided their initial urine drug screen on 5/7/2013. The facility did not have documentation of the results of the drug screen urinalysis from the CLIA and Department of Health approved laboratory prior to the administration of a narcotic agent. Patient # 1 was required to have monthly urine drug screens. The facility failed to document a urine drug screen for June 2013 in this patient record.
Patient # 2 was admitted on 12/3/2012 and received their first dose of Suboxone on 12/11/2012. There was a handwritten record showing an instant drug screen was completed on 12/11/2012. The record failed to include drug screen from the CLIA and Department of Health approved laboratory prior to the administration of a narcotic agent. Patient # 2 was required to have monthly urine drug screens. The facility failed to document a urine drug screen for March and May of 2013.
Patient # 3 was admitted on 4/8/2013. The patient received their first dose of Suboxone on 4/11/2013. The patient provided their initial urine drug screen on 4/11/2013. The facility did not have documentation of receiving the results back from the CLIA and Department of Health approved laboratory prior to the administration of a narcotic agent.
Patient # 4 was admitted on 9/11/2012 and discharged on 1/3/2013. The patient received their first dose of Subutex on 9/11/2012. The patient provided their initial urine drug screen on 9/11/2011. The facility did not have documentation of receiving the results back from the CLIA and Department of Health approved laboratory prior to the administration of a narcotic agent. Patient # 4 was required to have monthly urine drug screens. The facility failed to document a urine drug screen for October, November and December of 2012.
Patient # 5 was admitted on 11/30/2012. The patient received their first dose of Suboxone on 12/4/2012. There was a handwritten record showing an instant drug screen was completed on 12/18/2012. The record failed to include drug screen urinalysis results from the CLIA and Department of Health approved laboratory prior to the administration of a narcotic agent.
These findings were discussed with the facility director and clinical supervisor and were not disputed. The facility admitted to completing instant urine drug tests.
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Plan of Correction
Medical Director will only prescribe a narcotic agent (such as Suboxone) after receiving and reviewing the initial drug screen results from an approved laboratory. Instant drug screen results will not be utilized to determine appropriateness for treatment with a narcotic agent, from this point forward, without an Exception Request being granted by Licensing. Suboxone policy and procedures will be revised to reflect current procedures, including obtaining drug screens with sufficient time to be processed by the laboratory prior to being seen by the Medical Director.
All Suboxone clients will receive follow-up drug screens, at least monthly, which will be documented in client's chart when completed by a staff member. Clinical Director will train all staff at the quarterly staff meeting on 9/18/2013. Ongoing supervision and random chart reviews will occur to ensure compliance. Facility to be in full compliance by 9/30/2013. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on review of patient records, the facility failed to document a patient examination before determining the patient's initial dose and schedule in five of five patient records..
The findings include:
Five patient records were reviewed on August 20-21, 2013. All patient records were required to include a patient examination The facility failed to document a patient examination that included a review of the patients major organ systems and the patient's overall health status, infectious diseases; pulmonary, liver and cardiac abnormalities; dermatologic sequelae of addiction; vital signs; general appearance of head, eyes, ears, nose, throat, chest, abdomen, extremities, and skin; and physical evidence of injection drug use and dependence, as well as the physician's clinical judgment of the extent of physical dependence in patient records # 1, 2, 3, 4 and 5.
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Plan of Correction
Before determining a client's initial dose and schedule for Suboxone, Medical Director will document a client's examination that includes a review of systems, overall health, infectious diseases, pulmonary, liver and cardiac abnormalities, dermatologic sequelae of addiction, vital signs, general appearance of head, eyes, ears, nose, throat, chest, abdomen, extremities, and skin; physical evidence of injection drug use and dependence, as well as the physician's clinical judgment of the extent of physical dependence in client's records. Though these items have been part of the evaluation, documentation will be more concise and inclusive. Clinical Director will randomly review charts for compliance. Medical Director has been notified of these documentation requirements and adapted immediately upon notification by auditor. Facility in full compliance by 9/12/2013. |
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 client record review, the facility failed to complete psychosocial evaluations as stated in agency policy in two of seven client records.
The findings include:
Seven client records were reviewed on August 20, 2013. Seven client records were required to have a psychosocial evaluation completed by the second individual session, as per agency policy. Client records # 2 and 3 did not contain a psychosocial evaluation that was documented as completed by the second individual session.
Client #2 was admitted to outpatient treatment on December 3, 2012. A psychosocial evaluation was due to be completed by the second individual session. Documentation of a psychosocial evaluation was missing for client #2.
Client #3 was admitted to outpatient treatment on May April 8, 2013. A psychosocial evaluation was due to be completed by the second individual session. The psychosocial evaluation was completed on April 22, 2013, however, there was no documentation of client problems or needs, or coping mechanisms.
The findings were reviewed with the facility director and the clinical supervisor and were not disputed.
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Plan of Correction
Clinical director will ensure that all counselors complete a psychosocial evaluation on clients, according to the timeline set in the policy and procedure manual. Psychosocial evaluations must also include documentation of client problems or needs, or coping mechanisms. Counselors will be re-trained at the quarterly all-staff meeting on 9/18/2013 regarding psychosocial evaluations. Clinical Director will then perform random chart audits and ongoing individual supervision to ensure compliance. Facility to be in full compliance by 9/30/2013. |
709.93(a) 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:
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Observations
Based on the review of patient records, the facility failed to ensure the physician signed and dated each medical progress note.
The findings include:
Five patient records were reviewed on August 20-21, 2013. These five patients were receiving Suboxone or Subutex services by the facility medical director. The medical director documented his medical notes on the computer. The physician did not sign and date each medical progress note in patient records # 1, 2, 3, 4 and 5.
This finding was discussed with the facility director and clinical supervisor and was not disputed.
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Plan of Correction
Secure electronic medical records have been kept by the Medical Director on each client. To be in compliance with licensing, the Office Manager and/or Clinical Director will begin to print out each dated progress note, when completed, and present to the Medical Director for his signature the day of client's visit. Notes will then be filed in client's chart by the office staff. Medical Director has been notified of this requirement and has already come into compliance with this regulation. Clinical Director, Office Manager and Project Director will work together to ensure ongoing compliance through random chart audits. Facility to be in full compliance 9/12/2013. |