INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 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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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 Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 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.
Employee #6 was hired as a counselor on May 25, 2023 and was still in that position at the time of the inspection. Her training was due no later than May 25, 2024; however, the HIV/AIDS training was not completed until June 23, 2024 and the TB/STD training was not completed as of the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A Documented review of 704.11(c)(1) will be completed with all counselors by 8/31/2024. To ensure ongoing compliance with 704.11(c)(1) a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of Mandatory Communicable Disease Training requirements for all current employees and new hires. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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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 #2 was admitted on December 15, 2023 and was still active at the time of the inspection.
Client #3 was admitted on April 23, 2024 and was still active at the time of the inspection.
Client #4 was admitted on January 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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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 2,3 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)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of six client records reviewed.
Client #2 was admitted on December 15, 2023 and was still active at the time of the inspection.
Client #5 was admitted on February 22, 2024 and discharged on July 22, 2024.
Client #6 was admitted on October 23, 2023 and discharged on March 14, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A Documented review of 709.92(a)(2) will be completed with all counselors by 8/31/2024. The comprehensive treatment plan for client #2 will be updated to reflect type and frequency of treatment and rehabilitation service by 8/31/2024. To ensure ongoing compliance with 709.92(a)(2), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of treatment plans. |
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.
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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 #3 was admitted on April 23, 2024 and was still active at the time of the inspection. A case consultation was completed on April 23, 2024 and the next one was due no later than June 23, 2024: however, none was completed.
Client #4 was admitted on January 31, 2024 and was still active at the time of the inspection. A case consultation was completed on February 21, 2024 and the next one was due no later than April 22, 2024; however, none was completed.
Client #5 was admitted on February 22, 2024 and discharged on July 22, 2024. A case consultation was completed on April 9, 2024 and the next one was due no later than June 9, 2024; however, it was not completed until July 22, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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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 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.
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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 one out of three 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 23, 2023 and discharged on March 14, 2024. A follow up was due no later than May 14, 2024; however, none was not completed.
This finding was 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 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. |