INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on May 11, 2020 at approximately 1:00 pm, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. All fire extinguishers in the facility were last inspected in July of 2019.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
ON 5.13.2021 the local fire company came to the location and inspected our fire extinguishers. We have created a policy where the site director will annually inspect the fire extinguishers to ensure compliance. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to ensure that all informed and voluntary consent to release information forms were signed and dated by the client in one of seven records reviewed.
Client #6 was admitted June 17, 2020 and was discharged September 28, 2020. A release of information form was signed and dated by the witness on June 17, 2020; however, the consent form was not signed and dated by the client.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/20/2021 the clinical supervisor conducted a record audit identifying all patient records that did not have signed consent to release information forms. On this date, the counseling staff was trained on the proper completion of clinical documentation including completing consent forms at the time of admission. The clinical supervisor will audit patient records to ensure Naaman Center remains in compliance with this regulation. The clinical supervisor will conduct quarterly chart audits to ensure compliance is maintained. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that all informed and voluntary consent to release information forms indicated a copy of a client consent was offered to the client in one of seven client record reviewed.
Client #1 was admitted February 13, 2019 and was active at the time of inspection. A release information form was signed and dated by the client on February 13, 2019; however, there was no documentation that a copy of the form was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 5.20.21 the counseling staff was trained on the proper completion of clinical documentation including completing consent forms and offering a copy to the clients at the time of admission. The clinical supervisor will audit patient records to ensure Naaman Center remains in compliance with this regulation. The clinical supervisor will conduct quarterly chart audits to ensure compliance is maintained. |
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 a complete client record, which is to include follow-up information, in two of two applicable records reviewed.
Client #6 was admitted June 17, 2020 and was discharged September 28, 2020.
Client #7 was admitted November 23, 2020 and was discharged April 27, 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 5/20/2021 the clinical supervisor conducted a record audit identifying all patient records that did not have a follow-up contact. On this date, the counseling staff was trained on the proper completion of clinical documentation including Patient follow-up procedures according to Naaman company policy. Naaman's clinical supervisor will conduct ongoing chart audits to ensure that the counselors are following DDAP and company policy on patient follow-up procedures. |