INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16 through August 17, 2011 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on review of the staffing requirements summary report form completed by the facility on August 15, 2011 and an interview with the facility director/project director on August 16, 2011, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, employee # 5 exceeded the maximum ratio of 35:1. Employee # 5 has a caseload of 40:1.
The facility's standard work week is based on 40 hours. Employee # 5 is a contract employee who works 11 hours a week. Employee # 5 has a caseload of 11 assigned clients.
Employee # 5 (11/40 =.275 FTE) (11 clients/ .275 FTE =40:1)
This issue was addressed with administrative staff on August 16 and August 17, 2011.
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Plan of Correction
All counselors will comply with client/counselor ratio of no more than 35:1 regarding the FTE formula utilized by Licensing Department. Employee #5 will have caseload adjusted to meet this requirement. Counselor caseloads will be monitored weekly by Clinical Supervisor to insure compliance. Clinical Supervisor will report to Facility Director each month to insure and maintain compliance. Facility Director and Clinical Supervisor will work together and be responsible for achieving and maintaining compliance by October 1, 2011. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
The findings included:
Eight client records were reviewed on August 16, 2011. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Eight client records required an informed and voluntary consent from the client. The facility failed to obtain an informed an voluntary consent for the disclosure of client information to the funding entity in client records # 3, 8, and 7. The facility exceeded the limits imposed by 4 Pa. Code 255.5 (b) in client records # 1 and 7.
Client # 1 was admitted on February 4, 2011. On 4/6/2011,a fax was sent to the probation officer that provided the results of a urine drug test which exceeded the limits imposed by 4 Pa. Code 255.5 (b).
Client # 7 was admitted April 27, 2011. A letter dated August 12, 2011 was faxed to the probation officer providing the probation officer with information that exceeded the limits imposed by 4 Pa. Code 255.5 (b). The letter documented requirements imposed on the client while in treatment.
On August 17, 2011 the project/facility director and clinical supervisor were interviewed. They confirmed that informed and voluntary consents had not been completed by the clients # 3, 7, and 8 for the funding entity.
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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. The Office Manager will be responsible for office staff compliance. Clinical Supervisor will be responsible for clinical staff compliance. All staff will be individually trained with their appropriate supervisor.
All clinical staff will be retrained regarding releases and confidentiality regulations at their quarterly clinical meeting scheduled for September 20, 2011. Topics discussed will include what can and cannot be released to outside agencies per state regulations, to include probation officers, to remain in compliance with confidentiality regulations. Office Manager and Clinical Supervisor will meet together with Project Director to insure compliance. Clinical Supervisor is ultimately responsible for achieving and maintaining compliance regarding all client consent forms. Agency will be in compliance by 10/1/2011. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on review of the facility policy and procedure manual and client records, the facility failed to document client medical histories.
The findings include:
The facility's policy and procedures were reviewed on August 16, 2011. According to policy, "medical history information shall be obtained regarding both client and family medical history, including symptoms and illnesses." The facility failed to follow their policy, failing to obtain a family medical history in client records # 1, 2, 3, 4, 5, 6, 7, and 8.
The clinical director confirmed this finding on August 17, 2011.
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Plan of Correction
Family Medical History was erroneously omitted from a revised assessment tool. This has now been corrected by the Clinical Supervisor. Clinical Supervisor has distributed to and notified all office and clinical staff regarding the revision of the assessment tool to include Family Medical History. All old copies will be replaced with this corrected tool. Clinical Supervisor will perform weekly random record reviews of all counselors' charts to insure and maintain compliance. Re-training of required documentation will take place individually as well as at the quarterly clinical team meeting scheduled for September 20, 2011. Facility will be in compliance by 10/1/2011. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of the policy and procedure manual and client records, the facility failed to document a drug and alcohol history that included lengths and patterns and the amount of the substance being abused in five of eight client records.
The findings include:
The facility's policy and procedures were reviewed on August 16, 2011. According to the facility policy and procedure, "drug and alcohol history information shall be documented concerning the substances most frequently abused, length and patterns of use, and prior treatment experiences." Eight client records were reviewed in August 17, 2011. All client records were required to include a drug and alcohol history. Client records # 2, 4, 6, 7, and 8 failed to include a drug and alcohol history that included the amounts along with lengths and patterns of drug and/or alcohol use.
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Plan of Correction
The Clinical Supervisor shall insure that counselors document amounts, along with lengths and patterns of use in client drug and alcohol histories consistently. A training has been set up for 9/20/2011 to address this matter with clinical staff. Clinical Supervisor will provide the training. Subsequent to training, the clinical supervisor will meet with counselors weekly and review a few individual client records with each counselor for the next month and continue addressing deficiencies from State Audit and insure counselors are documenting appropriately. Each week, the clinical supervisor will review a different set of charts. After a month of one on one review of client records with individual counselors, the clinical director shall continue with regular quality assurance reviews at least once a month and additional trainings will be scheduled as needed, should there be any deficiencies noted. |
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 client records, the facility failed to document a treatment plan update in two of five client records.
The findings include:
Eight client records were reviewed on August 17, 2011. Five client records were required to have a treatment plan update . Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a timely treatment plan update in client record # 1. The facility failed to document a treatment plan update in client records # 4.
Record #1 - The client was admitted on February 4, 2011. The comprehensive treatment plan was completed on March 8, 2011. A treatment plan update was due by May 8, 2011. A new treatment plan was completed June 28, 2011, this was 51 days late.
Record #4 - The client was admitted on April 15, 2011. The comprehensive treatment plan was completed on May 3, 2011. A treatment plan update was completed on June 14, 2011. A treatment plan update was due by August 14, 2011 and was not completed. The facility failed to document the completion of a treatment plan update as of August 17, 2011.
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Plan of Correction
The Clinical Supervisor shall insure that counselors document treatment plan updates consistently and timely. A training has been set up for 9/20/2011 to address this matter with clinical staff. Clinical Supervisor will provide the training. Subsequent to training, the clinical supervisor will meet with counselors weekly and review a few individual client records with each counselor for the next month and continue addressing deficiencies from State Audit and insure counselors are documenting appropriately. Each week, the clinical supervisor will review a different set of charts. After a month of one on one review of client records with individual counselors, the clinical supervisor shall continue with regular quality assurance reviews at least once a month and additional trainings will be scheduled as needed, should there be any deficiencies noted.
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records, the facility failed to document medication records in three of four client records.
The findings include:
Nine client records were reviewed on August 17, 2011 and August 18, 2011. Four client records were reviewed for the outpatient other chemotherapy activity. Medication records were required in four client records. The facility did not document medication records in client record # 3, 7, and 9.
Client # 3 was prescribed suboxone. The facility failed document the medication information on the "Patient Medication Record." The client record failed to include a Patient Medication Record.
Client # 7 was prescribed subutex. The facility had the client's medication documented on a "Patient Medication Record," however, the form failed to include the client's name. There was no way to verify that the medication record belonged to the client due to the lack of the form being completed with client identifying information.
Client # 9 was prescribed suboxone. The client record failed to include a Patient Medication Record.
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Plan of Correction
Clinical Supervisor will insure that Patient Medication Records are included in all client charts who are prescribed medications by Naaman Center's Medical Director. Clinical Supervisor will also insure that all prescribed medications by Medical Director are documented on the Patient Medication Record by reviewing charts periodically. A quarterly clinical team meeting is scheduled for 9/20/2011, at which time additional training will occur by Clinical Supervisor to clinical team and Medical Director regarding importance and completion of this Medication Record. Office staff will be trained by the Office Manager to insure Medication Record is attached to client chart and client name is on the Medication Record prior to being given to Medical Director for appointment. Clinical Supervisor will do quality assurance by monthly selecting random charts to insure ongoing compliance. Facility to be compliant by 10/20/2011. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an interview with the Project/Facility Director and the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient other chemotherapy treatment activity.
The findings included:
During the licensing inspection conducted on August 16 through 17, 2011, client census material provided by the Project/Facility Director and an interview with the Project/Facility Director confirmed that the current census for active clients in the outpatient other chemotherapy activity was at 16. The maximum approved capacity on the day of the inspection was 15.
An interview with the project/facility director took place on August 18, 2011. It was determined during the review of client records at the satellite facility on August 18, 2011, that clients at the satellite facility were also receiving "outpatient other chemotherapy services" at this facility. There were currently two clients at the facility that were not included in the census that was provided to the licensing inspector on August 16 and August 17, 2011. When these clients were added to the census the facility was over their approved maximum capacity.
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Plan of Correction
Project Director sent request to the Division Director on 8/30/2011 to increase the maximum capacity from 15 to 30, to accommodate the increased number of clients we provide service for under outpatient other chemotherapy treatment. Until approval is granted, Clinical Supervisor will insure compliance by not permitting more than 15 maximum current clients in this category. Clinical Supervisor will notify Medical Director of this limitation, as well as provide training to entire clinical team at quarterly clinical team meeting scheduled for 9/20/2011. Clinical Supervisor will closely monitor the caseload for other chemotherapy treatment activity for insuring and maintaining compliance. Facility to be in compliance by 10/20/2011. |