INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18 - 19, 2021 by staff from the 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.
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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
The facility failed to provide documentation that unannounced fire drills were conducted between October 2020 and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The prince street location is one office located in the Water Street rescue mission. The clinical supervisor will collaborate with the Water Street rescue mission team to conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
The facility failed to provide documentation that fire drills were conducted during normal staffing conditions between October 2020 and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The prince street location is one office located in the Water Street rescue mission. The clinical supervisor will collaborate with the Water Street rescue mission team to conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to provide documentation that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative between October 2020 and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The prince street location is one office located in the Water Street rescue mission. The clinical supervisor will collaborate with the Water Street rescue mission team to conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to provide documentation that alternate exits routes were used during fire drills between October 2020 and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The prince street location is one office located in the Water Street rescue mission. The clinical supervisor will collaborate with the Water Street rescue mission team to conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
The facility failed to provide documentation that fire drills were conducted on different days of the week and at different times of the day between October 2020 and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The prince street location is one office located in the Water Street rescue mission. The clinical supervisor will collaborate with the Water Street rescue mission team to conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The facility failed to provide documentation that fire alarm or smoke detector were set off during each drill between October 2020 and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the deficiency and created a fire drill log and conducted staff training on 9/15/21. The prince street location is one office located in the Water Street rescue mission. The clinical supervisor will collaborate with the Water Street rescue mission team to conduct fire drills that meet all fire safety 705.28 regulations. The clinical supervisor or counselor on site will continue to do monthly fire drills. The Naaman Center clinical supervisor will monitor monthly fire drill chart for compliance. Through this process the facility will ensure to provide documentation that fire drills were conducted during normal staffing conditions. The clinical supervisor will also document that a written fire drill record was conducted which included the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative, using alternate exits and at different time during business hours. The clinical supervisor will also document that fire alarm or smoke detector were set off during each drill. |
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 have a complete client record which included aftercare plan in one of two records.
Record #3 was admitted on July 08, 2020 and was discharged on November 15, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical chart missing the aftercare plan on 9/15/21. The clinical supervisor met with the primary therapist on 9/15/21 and re-trained regarding proper documentation for the after-care plan. The therapist will ensure that all client charts have completed aftercare plans prior discharge. The clinical supervisor will monitor charts monthly for compliance. |
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 have a complete client record which included discharge summary in one of two records.
Record #3 was admitted on July 08, 2020 and was discharged on November 15, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical chart missing the discharge summary on 9/15/21. The clinical supervisor met with the primary therapist on 9/15/21 and re-trained regarding proper charting documentation including proper completion of the discharge summary. The client record was also corrected at this time and discharge summary was entered. The therapist will ensure that all discharged client charts have completed discharge summaries. The clinical supervisor will monitor charts monthly for compliance. |
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 have a complete client record. Follow up information missing in two of two records. There was no documentation of follow up at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed clinical charts on 9/15/21. The clinical supervisor met with clinical team and administrative staff at this time. The administrative staff will email or mail follow-up letters to all clients within 60 days of discharge in accordance with the Naaman Center follow-up policy. The clinical supervisor, will monitor charts monthly for compliance.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #3 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a case manager on January 01, 2019 and was due to have the communicable disease trainings no later than January 01, 2021. There was no documentation of HIV/AIDS training and the TB/STD training completion at the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed annual training plan on 9/15/21. The Clinical team met at this time and the clinical supervisor advised staff of the plan to obtain communicable disease trainings per DDAP regulations. The current training plans was reviewed, and staff are on target for current training year. The clinical supervisor will monitor each individual training plan to ensure compliance during 2021 training year. |