INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on August 22, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Naaman Center ( Vine Street) 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff CPR/first aid certification documentation, the facility failed to ensure that at least one person trained in CPR skills was onsite during the project's hours of operation.
Findings:
Based on a review of staff schedules and staff CPR/first aid certification cards, the facility did not have any staff trained in these skills to provide sufficient coverage during the facility's hours of operation.
Staff member # 4 had an expired CPR/First Aid certification from June 18, 2012 until their renewal certification on August 18, 2012.
During the time that the staff member's certification was expired he provided group therapy on Wednesday evenings from 5:00 P.M. to 6:00 P.M. with no other staff in the facility with CPR certification.
The Project/ Facility Director, and the counselor, confirmed this finding on August 22, 2012 at 3:00 P.M.
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Plan of Correction
Executive Director will see to it that required CPR certifications and First Aid Training are completed in a timely fashion as to insure all required employees are compliant on an on-going basis. Staff #4 noted his 1 month lapse and attended his re-certification training on August 18, 2012, which is good for 2 years. In the future, Executive Director will closely monitor staff CPR training requirements by keeping a log of when renewals for CPR certification are coming up, along with other required trainings, to insure compliance in this area. All new staff for satellite locations will be required to have CPR prior to being the sole counselor at any location. Facility to be in compliance by 9/30/2012. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan.
The findings include:
Six client records were reviewed on August 22, 2012. Preliminary treatment plans were required in six client records. The facility did not include a preliminary treatment plan in client record # 4.
The client was admitted on June 11, 2012. There was no documentation in the client record at the time of this inspection.
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Plan of Correction
Clinical Supervisor will be responsible to insure all counselors have a Preliminary Treatment Plan in each client's chart within the first three sessions of treatment, per facility policy. An all-clinical staff meeting is scheduled for September 12, 2012 and will be facilitated by Clinical Supervisor. Re-training will occur to insure compliance in this area. Clinical Supervisor will conduct random and periodic chart reviews to insure on-going compliance. Counselors will also receive individual supervision as another way of insuring compliance. Facility to be in full compliance by 10/31/2012. |
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:
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Observations
Based on review of client records, the facility failed to complete an individual treatment plan in accordance with facility policy in one of five client records.
The findings include:
Six client records were reviewed on August 22, 2012. Comprehensive treatment plans were required in five of six client records. Facility policy stated that treatment plans would be completed by the third session.
There was no documentation of a treatment plan in Client record # 4. Client # 4 was admitted on June 11, 2012. Documentation in the client record indicated the client had been involved in more than three sessions.
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Plan of Correction
Clinical Supervisor will be responsible to insure that Preliminary Treatment Plans will be completed and filed in every client's chart by the third session of individual treatment, per facility policy. Re-training regarding this policy will be completed on September 12, 2012, at an all clinical staff meeting facilitated by the Clinical Supervisor. In an effort to maintain compliance, Clinical Supervisor will also meet individually with each counselor during supervision times to review this process as well. Clinical Supervisor will do random and periodic chart reviews of each counselor to insure compliance in this area. Facility to be in full compliance by 10/31/2012. |
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 document an aftercare plan in one of two client records.
The findings include:
Three discharged client records were reviewed on August 22, 2012. One of the discharged clients reviewed was successfully discharged and required an aftercare plan. Client record #5 did not include documentation of an aftercare plan.
Client #5 was admitted to treatment on July 18, 2011 and successfully discharged on July 16, 2012. There was no documentation of an aftercare plan in client record #5.
An interview with the facility director took place on August 22, 2012 at which time it was confirmed that there was no documentation of an aftercare plan in client record #5.
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Plan of Correction
Clinical Supervisor will be responsible to insure that Aftercare plans are completed for those who require one per facility policy. Per facility policy, "Naaman Center will not prepare Aftercare Plans for clients who refuse to participate in developing an Aftercare Plan or have left treatment against project advice. Neither will Naaman Center prepare an Aftercare plan for client's being referred to another facility for futher treatment." These exceptions will be documented in client's chart. Clients who complete successfully and participate in the development of an Aftercare Plan will have this document filed in client's chart. A re-training of all counselors will occur on September 12, 2012 at an all-staff clinical meeting facilitated by the Clinical Supervisor. Following that meeting, random and periodic chart reviews will occur by Clinical Supervisor to insure ongoing compliance. Facility to be in full compliance by 10/31/2012. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plans for medical assistance clients.
The findings included:
Six client records were reviewed on August 22, 2012. Six of the thirteen client records are required to have a physician signature on the individual treatment plans. The individual treatment plans contained in client records # 2 did not contain a physician signature.
Client # 2 was admitted to outpatient treatment on July 12, 2012. The individual treatment and rehabilitation plan was developed on July 18, 2012, and did not include a physician signature.
The findings were reviewed with the facility director on August 22, 2012 and were not disputed.
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Plan of Correction
Executive Director will appoint Clinical Supervisor to be responsible for making sure all documents, including treatment plans, required to have the physician's signature are in compliance. This includes medical assistance clients. A re-training of all clinical staff will occur on September 12, 2012 at an all-clinical staff meeting facilitated by the Clinical Supervisor. Ongoing chart reviews will be random and periodic to insure compliance following this re-training. Clinical Supervisor will also address during individual supervision times of all counselors. Clinical Supervisor will be responsible to help facilitate physician signatures on required documents to insure compliance. Facility to be in full compliance by 10/31/2012. |