INITIAL COMMENTS
|
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 April 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in the record in one of seven records reviewed.
Client #5 was admitted June 4, 2019 and was discharged April 28, 2020. There was documentation of billing to the funding source; however, there was no consent to release form on file prior to the disclosure of information.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
On 4/28/2021 the clinical supervisor conducted a record audit identifying all patient records that did not have financial disclosure. On this date, the counseling staff was trained on the proper completion of clinical documentation including completing financial disclosures at the time of admission. The clinical supervisor will adult 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.
|
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 five of seven records reviewed.
Client # 1 was admitted September 25, 2019 and was discharged February 24, 2020. There was no follow-up information documented in the record at the time of the inspection.
Client #2 was admitted September 14, 2020 and was discharged November 16, 2020. There was no follow-up information documented in the record at the time of the inspection.
Client #3 was admitted July 8, 2020 and was discharged November 5, 2020. There was no follow-up information documented in the record at the time of the inspection.
Client #4 was admitted July 30, 2019 and was discharged April 28, 2020. There was no follow-up information documented in the record at the time of the inspection.
Client #6 was admitted March 31, 2020 and was discharged September 8, 2020. There was no follow-up information documented in the record at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
On 4/28/2021 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. |