INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Naaman Center was found to be not 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports (SRFSR), the project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the project.
The FTE for the project was calculated to be 12.2 which would require the project to employ one full-time clinical supervisor. As of July 1, 2017 the only full-time clinical supervisor was promoted to the position of project director and facility director of the Elizabethtown site.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 10/6/17, Naaman Center has been granted an exception regarding regulation 704.6(a). Naaman Center will adhere to the provisions specified in this exception. The Vine St. location (367079) already has a qualified and appointed Lead Counselor. Naaman Center is compliant with this standard as of now. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Seven client records were reviewed on September 25, 2017. The facility failed to ensure the confidentiality of a client record in record #2.
Client #2 was admitted on 4/24/17 and was an active client at the time of the licensing inspection. A 'Case Management Service Plan' dated 4/24/17 was found in the client record but this document had another client's name documented on it.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The misfiled document was removed from the record of client #2. Facility staff were informed of the citation and retrained about chart filing and confidentiality on 10/4/17 by the Project Director at a team meeting. Only documents for the specified client can be in the client chart. The Lead Counselor conducts regular quality control chart reviews and will continue to provide supervision and guidance regarding this. The facility is in full compliance as of now. |
709.28 (c) 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.
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Observations
Seven client records were reviewed on September 25, 2017. The facility failed to obtain a valid consent to release information in client records, #4, & 7.
Client #4 was admitted on 1/9/17 and was discharged on 5/17/17. A facsimile transmission to a probation officer dated 5/26/17 was contained in the record however there was no consent to release information to this person.
Client #7 was admitted on 2/14/17 and was discharged on 5/25/17. There was no valid consent to release information to the client's funding source.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Facility staff were informed of the citation and retrained about confidentiality and consent to release information on 10/4/17 by the Project Director at a team meeting. Every release of client information must have a current and valid consent to release information. The Lead Counselor conducts regular quality control chart reviews and will continue to provide supervision and guidance regarding this. An additional funding source consent template was created for the specific funding involved with client #7 to minimize the risk of this being missed in the future. The facility is in full compliance as of now. |