INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2023 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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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 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 three out of six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed by the second session with the therapist.
Client #3 was admitted on January 10, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was completed on the sixth session.
Client #4 was admitted on June 14, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was completed on the third session.
Client #6 was admitted on January 25, 2023 and discharged on May 11, 2023. The comprehensive treatment plan was completed on the third session.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical Director reviewed audit Findings with clinical supervisor and lead counselors on 7-27-23. The Clinical Supervisor and Lead Counselor will review charts to verify compliance and ensure all comprehensive treatment plans are signed at the 2nd individual counseling session as stated in our Naaman Center policy. Counselors not in compliance will be notified during supervision sessions with the Lead Counselor. Compliance will be met by 8/17/23. |
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 two out of six client records reviewed.
Client #2 was admitted on April 28, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 11, 2023 with no type or frequency identified.
Client #3 was admitted on January 10, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on March 10, 2023 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 6, 2022 licensing inspection.
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Plan of Correction
The clinical Director reviewed audit Findings with clinical supervisor and lead counselors on 7-27-23. The Clinical Supervisor and Lead Counselor will review charts to verify compliance and ensure all treatment plans have type and frequency of service clearly documented. Counselors not in compliance will be notified during supervision sessions with the Lead Counselor. Changes have been made to the treatment plan template to assist counselors in entering the type and frequency of service. Compliance will be met by 8/17/23. |
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 three 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 #4 was admitted on March 8, 2023 and was discharged on June 14, 2023. A case consultation was completed on March 9, 2023 and the next one was due no later than May 9, 2023; however, it was not completed until May 24, 2023.
Client #5 was admitted on admitted on September 6, 2022 and was discharged on February 16, 2023. A case consultation was completed on September 6, 2022 and the next one was due no later than November 6, 2022; however, none was completed.
Client #7 was admitted on January 24, 2023 and was discharged on April 19, 2023. A case consultation was completed on January 24, 2023 and the next one was due no later than March 24, 2023; however, it was not completed until April 13, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 6, 2022 licensing inspection.
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Plan of Correction
The clinical Director reviewed audit Findings with clinical supervisor and lead counselors on 7-27-23. The Clinical Supervisor and Lead Counselor will review charts to verify compliance and ensure all counselors are following Naaman Center policy of entering case consults at least every 60 days. Counselors not in compliance will be notified during supervision sessions with the Lead Counselor. Compliance will be met by 8/17/23. |