INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 23, 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:
|
Plan of Correction
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #5 was hired on August 2, 2023 as a counselor and was still in the position as of the date of the inspection. The training was completed on August 25, 2023.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Documented education will be provided to staff regarding 705.28 (c) (4) The Executive Director will conduct quarterly training audits to ensure ongoing compliance with regarding 705.28 (c) (4) |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #5 was hired on August 2, 2023 as a counselor and was still in the position as of the date of the inspection. The training was completed on August 25, 2023.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Documented education will be provided to staff regarding705.28 (d) (3). The Executive Director will conduct quarterly training audits to ensure ongoing compliance with regarding 705.28 (c) (4) for all new hires and staff members.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in three out of seven applicable records reviewed.
Client #1 was admitted on January 18, 2024 and was still active at the time of the inspection.
Client #3 was admitted on January 8, 2024 and was still active at the time of the inspection.
Client #4 was admitted on November 23, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A Documented review of 709.91(b)(6) will be completed with all counselors by 8/31/2024. The Psychosocial assessment data for clients 1, 3, and 4 will be completed by 8/31/2024. To ensure ongoing compliance with 709.91(b)(6), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of psychosocial data. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed at the second session with the counselor.
Client #1 was admitted on January 18, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 11, 2024; however, it was not completed until April 1, 2024.
Client #4 was admitted on November 22, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 7, 2023; however, it was not completed until January 4, 2024.
Client #5 was admitted on January 25, 2024 and discharged on May 17, 2024. A comprehensive treatment plan was due no later than March 14, 2024; however, it was not completed until March 28, 2024.
Client #6 was admitted on October 12, 2023 and discharged on March 18, 2024. A comprehensive treatment plan was due no later October 30, 2023; however, it was not completed until November 13, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 18, 2023 licensing inspection.
|
Plan of Correction
A Documented review of 709.92(a) will be completed with all counselors by 8/31/2024. The comprehensive treatment plans for clients 1, and 4 will be completed by 8/31/2024. To ensure ongoing compliance with 709.92 (a), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of treatment plans. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of five applicable records reviewed.
Client #1 was admitted on January 18, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 6, 2024 and an update was due no later than July 4, 2024; however, it was not completed until July 11, 2024.
Client #3 was admitted on January 8, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 2, 2024 and an update was due no later than March 3, 2024; however, it was not completed until April 5, 2024.
Client #4 was admitted on November 22, 2023 and was still active at the time of the inspection. A treatment plan update was completed on April 23, 2024 and the next update was due no later than June 23, 2024; however, it was not completed until June 27, 2024.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A Documented review of 709.92(b) will be completed with all counselors by 8/31/2024. To ensure ongoing compliance with 709.92(b), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of treatment plan updates every 60 days. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 60 days following admission.
Client #1 was admitted on January 18, 2024 and was still active at the time of the inspection.
Client #2 was admitted on March 12, 2024 and was still active at the time of the inspection.
Client #3 was admitted on January 8, 2024 and was still active at the time of the inspection.
Client #4 was admitted on November 23, 2023 and was still active at the time of the inspection.
Client #5 was admitted on January 25, 2024 and discharged on May 17, 2024.
Client #6 was admitted on October 12, 2023 and discharged on March 18, 2024.
Client #7 was admitted on April 2, 2024 and was discharged on June 5, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 18, 2023 licensing inspection.
|
Plan of Correction
A Documented review of 709.93(a)(8) will be completed with all counselors by 8/31/2024. The client record for clients 1,2,3,and 4 will be updated to include current case consultation notes by 8/31/2024. To ensure ongoing compliance with, 709.93(a)(8) a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of case consultation notes every 60-days following admission in accordance with the facilities policy and procedure manual.
|
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.
|
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 one out of two applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 60 days following discharge.
Client #6 was admitted on October 12, 2023 and discharged on March 18, 2024. A follow up was due no later than June 18, 2024; however, none was not completed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the July 18, 2023 licensing inspection.
|
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 client #6 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 |