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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from August 2023 - July 2024, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of May 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Documented education will be provided to staff regarding 705.28 (d) (1). The Executive Director will conduct monthly reviews of the Fire Drill logs to ensure ongoing compliance with 705.28 (d) (1). |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs from August 2023-July 2024, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Documented education related to 705.28 (d) (7) will be provided to all staff by 8/31/2024. The Executive Director will conduct monthly reviews of the Fire Drill logs to monitor the documentation of whether a fire alarm or smoke detector was utilized during the fire drill. |
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 two out of six applicable records reviewed.
Client #1 was admitted on May 15, 2024 and was still active at the time of the inspection.
Client #3 was admitted on April 30, 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 will be completed with all counselors by 8/31/2024. The Psychosocial assessment data for clients 1 and 3 will be completed by 8/31/2024. To ensure ongoing compliance with 709.91, a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of psychosocial data. |
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 five out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed by the second session.
Client #1 was admitted on May 15, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due on June 17, 2024; however, it was completed on July 9, 2024.
Client #2 was admitted on June 5, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due on June 26, 2024; however, it was completed on July 10, 2024
Client #3 was admitted on April 30, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due May 29, 2024; however, it was not completed until June 12, 2024.
Client #4 was admitted on February 14, 2024 and discharged on May 9, 2024. No comprehensive treatment plan was completed.
Client #6 was admitted on January 31, 2024 and discharged on May 29, 2024. A comprehensive treatment plan was due February 28, 2024; however, it was completed on May 30, 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 will be completed with all counselors by 8/31/2024. The comprehensive treatment plans for clients 1, 2, 3, 4, and 6 will be completed by 8/31/2024. To ensure ongoing compliance with 709.92, a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of treatment plans. |
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 one out of one applicable records reviewed.
Client #6 was admitted on January 31, 2024 and discharged on May 29, 2024. A comprehensive treatment plan was completed on March 6, 2024 and an update was due no later than May 6, 2024; however, it was not completed until May 30, 2024.
This finding was reviewed with facility staff during the 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)(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 provide a complete client record, which is to include aftercare information in one out of two applicable discharged records reviewed.
Client #4 was admitted on February 14, 2024 and was discharged on May 9, 2024.
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)(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. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three records reviewed.
Client #4 was admitted on February 14, 2024 and was discharged on May 9, 2024.
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)(10) will be completed with all counselors by 8/31/2024. A discharge summary for Client #4 will be completed by 8/31/2024. To ensure ongoing compliance with 709.93(a)(10), a quarterly audit will be conducted by Clinical Supervisors to monitor the completion of discharge summaries. |
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 three 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 #4 was admitted on February 14, 2024 and was discharged on May 9, 2024.
Client #5 was admitted on December 20, 2023 and was discharged on February 1, 2024.
Client #6 was admitted on January 31, 2024 and discharged on May 29, 2024.
These findings were 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 Clients 4, 5, and 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 |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/30/2024, a sign identifying operational hours was placed in a conspicuous location for public visibility. The Executive Director will conduct quarterly reviews of the location to ensure the project hours remain posted for public visibility. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/30/2024, a sign was posted on the front door with emergency phone numbers. The sign is now conspicuously posted for public visibility. The Executive Director will monitor compliance with this standard quarterly to ensure the sign containing emergency phone numbers remains posted. |