INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30, 2010 and August 31,2 010 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 and a plan of correction is due on September 22, 2010.
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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 the fire drill log, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
The administrative documentation of the fire drill log was reviewed on August 30, 2010. The last twelve months were reviewed for documentation of the fire drills being conducted. The facility failed to conduct an unannounced fire drill in April 2010.
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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 by 10/1/2010. The Executive Director has designated the Office Manager to conduct these monthly fire drills or she will herself conduct the drill each month and insure that it will be done monthly. As an additional safeguard, monthly reminders will automatically pop up from Microsoft Outlook to insure compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on the review of administrative documentation and an interview with the facility Project Director/ Executive Director, the facility failed to make the annual report available to the public.
The findings include:
Administrative documentation was reviewed on August 30, 2010. Per regulation, when a facility is publicly funded, the governing body must make the annual report available to the public. The facility was unable to provide documentation that the annual report was made available to the public. An interview with the facility Project/Executive Director on August 30, 2010 at 3:15 p.m. confirmed that the report was not made available to the public.
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Plan of Correction
The Executive Director will insure that Naaman Center's Annual Report henceforth will be made available to the public and will so be documented. This issue will be corrected by December 31, 2010. The method of distribution will through the Naaman Center newsletter, mailed to the database of supporters. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on the review of administrative documentation and an interview with the facility Project Director/ Executive Director, the facility failed to include the activities and accomplishment of the preceding year in their annual report.
The findings include:
Administrative documentation was reviewed on August 30, 2010. Per regulation, when a facility is publicly funded, the governing body shall have an annual report that includes the activities and accomplishments of the preceding year. The facility Project/Executive Director was interviewed and confirmed that the activities and accomplishments for the preceding year were not included in a written annual report.
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Plan of Correction
From this point forward, the Executive Director will insure that Naaman Center's written Annual Report will include, but not limited to, the activities and accomplishments of the preceding year. The Annual Report will be completed for the fiscal year 2009-2010 by September 28, 2010. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of the administrative policy and procedure manual, client records, and an interview with the facility Project/ Executive Director and Clinical Supervisor, the facility failed to follow their policy on notification of client rights.
The findings include:
The facility policy and procedure manual was reviewed on August 30, 2010. The policy and procedure manual stated that "clients shall be informed of their rights during orientation and asked to sign off on the "Client Bill of Rights" (see Appendix 12 Intake/Orientation Forms). The client files were reviewed on August 31, 2010. The "Client Bill of Rights" form that was described in the policy and procedure manual was not being utilized in the client records. After an interview with the Project/Executive Director and the Clinical Supervisor on August 31, 2010 at 11:35 a.m. it was determined that the facility had changed their form and the current practice did not coincide with the policy in the facility policy and procedure manual. The facility failed to have a current policy and procedure in place in their administrative policy and procedure manual.
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Plan of Correction
Naaman Center's Policy and Procedural Manual will be revised by October 31, 2010 to accurately reflect the current procedures regarding distribution of Client Rights. The policy will read as follows: "Clients shall be informed of their rights during orientation and asked to sign off on a 'Receipt of Handbook Confirmation' form which includes a list of documents received, including the Client Bill of Rights. This signed document will then be filed in client's chart." Clinical Supervisor will meet with each counselor by October 31, 2010 to insure they are following through with this procedure. |
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 nine client records it was determined that the facility failed to document in the treatment plan update the client's progress as it relates to the goals identified in the individualized treatment and rehabilitation plan. Also, the facility failed to document a treatment plan update in four of six client records.
The findings were:
Nine client records were reviewed on August 31,2010. Six were required to have a treatment plan update. In four of six client records that required treatment plan updates, specifically #2, 7, 8, and 9, it was determined that the therapist failed to document in the treatment plan update of the client's progress as it related to the the goals identified in the individualized treatment and rehabilitation plan. In addition, new goals were identified in the treatment plan update without documenting the progress of previous goals identified. Also, in client record # 6 the facility failed to document a treatment plan update.
Client # 6 was admitted on 12/1/2009. The comprehensive treatment plan was completed on 12/11/2009. A treatment plan update was due on 2/11/2010. The client was discharged on 2/17/2010. The facility failed to document a treatment plan update in this client record.
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Plan of Correction
Clinical Supervisor will be responsible to insure counselors are completing the Master Treatment and Treatment Update Plans timely and correctly. Clinical Supervisor will meet with counselors individually to train on the correct usage of these forms by October 31, 2010. Treatment Plan Updates will be monitored by periodic chart reviews by Clinical Supervisor to insure client's progress as it relates to the goals identified in the Master Treatment and rehabilitation plans are addressed. Treatment Plan Updates will also be monitored by Clinical Supervisor to insure compliance of state mandate time frame of every 60 days, while in treatment. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on the review of the administrative policy and procedure manual, client records, and an interview with the facility Project/Executive Director, the facility failed to follow their policy on client follow-up.
The findings include:
The administrative policy and procedure manual was reviewed on August 30, 2010. According the to facility policy titled " Client Follow-Up Plan" it states:
"For all clients of Naaman Center, regardless of type of discharge, follow-up will be attempted and documented in clients chart. If successful, within one week, a letter will be sent confirming his/her successful completion. After 30 days, the primary counselor will attempt to call the client to support and encourage his/her continued abstinence, work in recovery, and progress toward sobriety. If the counselor is unable to reach the client via phone, a 30 day follow-up letter will be sent to the client as per general follow-up policy below. After 6 months, a letter will be sent to the client encouraging continued recovery and inviting the client to complete the enclosed longitudinal survey regarding recovery to be returned in the postage paid Naaman Center addressed envelope included in the mailing. All clients who have been recommended to treatment at the Namman Center will be sent a follow-up letter 30 days following discharge. This letter will contain an opportunity to inform staff regarding their progress in recovery and a satisfaction survey pertaining to their treatment at Naaman Center. This letter will contain a self addressed stamped envelope for ease of returning the survey and client report on recovery. Contacts and attempts to contact will be documented in the client's record."
Client records were reviewed on August 31, 2010. Follow-up documentation was not included in the client records. During an interview with the Project/Executive Director and the Clinical Supervisor on August 31, 2010 at 2:00 p.m. it was revealed that follow-ups were only being completed on successfully discharged clients and the facility was not conducting follow-up on administrative discharges or clients who leave against facility advice. It was confirmed that documentation of conducting follow-up was not being done by the counselor per their policy and that the follow-up was currently being conducted by the office personnel. Copies of the letters that were sent out by the office personnel were not being retained in the client files. The interview confirmed that the policy and procedure that was in place was not being practiced.
The facility failed to have a current policy and procedure in place in their administrative policy and procedure manual.
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Plan of Correction
Naaman Center's Follow-Up Policy will be revised to accurately reflect current follow-up procedures. This revision will take place by October 31, 2010. The revision will state: "For all clients of Naaman Center, regardless of type of discharge, follow-up will be attempted and documented in client's chart. They will be sent a follow-up letter within 60 days following discharge. This letter will contain an opportunity to inform staff regarding their progress in recovery and a satisfaction survey pertaining to their treatment at the Naaman Center. This letter will contain a self-addressed stamped envelope for ease of returning the survey and client report on recovery. "
The Executive Director has designated the Office Manager to be responsible for generating and mailing a follow-up letter to all discharged clients within 60 days following discharge. Effective 10/31/2010 a copy of this letter will be placed in client's chart by office staff.
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