INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2024 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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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 guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the aftercare plan must be completed prior to discharge.Client #6 was admitted on October 19, 2022 and was discharged on March 27, 2024. No aftercare plan was completed.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A Documented review of 709.93(a)(9) will be completed with all counselors by 8/31/2024. To ensure ongoing compliance with 709.93(a)(9), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of aftercare plans as applicable. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within guidelines established by the facility's policy and procedures manual in two out of four applicable records reviewed. The facility's policy and procedures manual states the discharge summary must be completed seven days following discharge.Client #5 was admitted on May 11, 2023 and discharged on February 27, 2024. A discharge summary was due no later than March 5, 2024; however, it was not completed until March 8, 2024. Client #7 was admitted on January 10, 2024 and was discharged on February 27, 2024. A discharge summary was due no later than March 5, 2024; however, it was not completed until March 8, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Documented review of 709.93(a)(10) will be completed with all counselors by 8/31/2024. To ensure ongoing compliance with 709.93(a)(10), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of discharge summaries. |
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 document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that follow up must be completed 60 days following discharge.Client #5 was admitted on May 11, 2023 and discharged on February 27, 2024. A follow up was due no later than April 28, 2024; however, none was not completed. Client #6 was admitted on October 19, 2022 and discharged on March 27, 2024. A follow up was due no later than May 28, 2024; however, none was not completed. Client #7 was admitted on January 10, 2024 and discharged on February 27, 2024. A follow up was due no later than April 28, 2024; however, none was not completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Documented review of 709.93(a)(11) will be completed with all counselors by 8/31/2024. Documented follow-up information for Clients 5,6, and 7 will be completed by 8/31/2024. To ensure ongoing compliance with 709.93(a)(11), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of follow up information |