INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Naaman Center Lancaster 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document 25 training hours for each counselor.
The findings include
Based on documentation reviewed in agency training files during the onsite inspection held August 26, 2013 it was determined that employee #1 did not have the minimum number of training hours for the last training year. Only 12 hours of appropriately documented training was found in the training file.
The findings were confirmed by the facility director.
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Plan of Correction
Clinical Director and Project Director shall work together to ensure that all personnel obtain the necessary hours of training required for the training year. The Clinical Director and Project Director will meet together on 09/12/2013 to discuss this matter and then work to ensure that necessary hours of training are received for each employee and documented in employee file. Project Director shall conduct an ongoing review of each employee's training situation quarterly to assess and ensure that required hours are met. Facility to be in compliance by 9/30/2013. |
709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of six client records.
The findings include:
Six client records were reviewed on August 26, 2013. Six of the six client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. Client record #2 included a signed and dated consent to release information that did not identify the name of the person, agency, or organization to whom disclosure was to be made.
The facility director confirmed the findings.
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Plan of Correction
Clinical Director and Project Director will meet on 9/12/2013 and work together to ensure client consents are completed accurately, to include identifying the name of the person, agency, or organization to whom disclosure was to be made. Clinical Director will re-train all counselors on the correct way to complete consents during a clinical meeting on 9/18/2013. Clinical Director will provide ongoing supervision sporadically throughout the year to ensure compliance. Clinical Director and Project Director will do intermittent chart reviews to ensure compliance as well. Facility to be in compliance by 9/30/2013. |
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 attempts in one of the three required records.
The findings include:
Three client records that required follow up were reviewed on August 26, 2013. Follow up was not documented in one of the three required client records.
Record # 7 was admitted on April 10, 2013 and discharged on June 6, 2013. The foll up attempt was due by August 6, 2013. There was no documentation of a follow up attempt.
The facility director confirmed the findings.
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Plan of Correction
Office Manager will insure the follow-up policy will be done according to Naaman Center's policy and procedure. A discharge letter will be sent out, including a follow-up survey, to all discharged clients within 60 days following discharge from Naaman Center. This letter will be generated by the Office Manager and mailed out by the office staff. A copy of this letter will then be placed in the client's chart by the office staff, to comply with this policy. Office Manager and administrative staff will be re-trained to insure compliance by 9/30/2013 by the Project Director. Project Director and Office Manager will work together and do sporadic reviews to ensure compliance. Facility to be in compliance by 9/30/2013. |