INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven applicable records reviewed.
Client #1 was admitted on January 2, 2024 and was still active at the time of the inspection. A treatment plan update was completed on March 26, 2024 and an update was due no later than May 26, 2024; however, it was not completed until May 30, 2024.
Client #5 was admitted on October 5, 2023 and was discharged on May 23, 2024. A comprehensive treatment plan was completed on January 23, 2024 and an update was due no later than March 23, 2024; however, it was not completed until May 23, 2024.
Client #6 was admitted on October 11, 2023 and was discharged on May 31, 2024. A treatment plan update was completed on January 3, 2024 and the next update was due no later than March 3, 2024; however, it was not completed until May 22, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 20, 2023 licensing inspection.
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Plan of Correction
A Documented review of 709.92(b) will be completed with all counselors by 8/31/2024. To ensure ongoing compliance with 709.92(b), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of treatment plan updates every 60 days. |
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 #1 was admitted on January 2, 2024 and was still active at the time of the inspection.
Client #2 was admitted on February 1, 2024 and was still active at the time of the inspection.
Client #3 was admitted on March 5, 2024 and was still active at the time of the inspection.
Client #4 was admitted on April 29, 2024 and was still active at the time of the inspection.
Client #5 was admitted on November 13, 2023 and discharged on May 23, 2024.
Client #6 was admitted on October 11, 2023 and discharged on May 30, 2024.
Client #7 was admitted on July 15, 2022 and was discharged on February 22, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 20, 2023 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 1,2,3, 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)(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 within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states the aftercare plan must be completed prior to discharge.
Client #5 was admitted on November 13, 2023 and discharged on May 23, 2024.
Client #6 was admitted on October 11, 2023 and discharged on May 30, 2024.
Client #7 was admitted on July 15, 2022 and was discharged on February 22, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 20, 2023 licensing inspection.
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Plan of Correction
A Documented review of 709.93(a)(9) will be completed with all counselors by 8/31/2024. To ensure ongoing compliance with 709.93(a)(9), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of aftercare plans as applicable. |