INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2022 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 September, 2021 - August, 2022, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of September, 2021 - August, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
P273 The Director created a document on a shared server, and this will be reviewed on the 15th of each month by the office manager and when a drill is missing the office manager will ensure the fire drill is completed at each site by the end of the month. All staff will be trained for fire drills, and someone will be appointed to complete and record fire drills. This staff will record this information in a shared digital location. This will be started in October and in compliance by 11.1.22. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in four out of six client records reviewed.
Client #2 was admitted on February 24, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 5, 2022 with no type or frequency identified.
Client #4 was admitted on May 4, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 11, 2022 with no type or frequency identified.
Client #5 was admitted on March 2, 2022 and was discharged on May 19, 2022. A comprehensive treatment plan was developed on May 1, 2022 with no type or frequency identified.
Client #7 was admitted on March 30, 2022 and discharged on May 25, 2022. A comprehensive treatment plan was developed on June 22, 2021 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Naaman Center Treatment Plan Template has been updated by the quality department prior to this inspection. The updated treatment plan header includes type, frequency, and modality. Naaman Center Lead Counselors are in the process of training staff on using the updated treatment plan template and overall treatment plan execution. Staff will be trained by the Lead Counselor in a clinical meeting and reminded in subsequent staff meetings, individual supervision and compliance will be met 11.1.22 |
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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of three applicable records reviewed.
Client #4 was admitted on May 4, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 11, 2022 and the next update was due no later than July 11, 2022; however, the next update was completed on September 5, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Lead Counselor will train all clinical staff on timeliness of treatment plan updates, tools to accomplish this, Naaman Center policies and regulations for treatment planning. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.1.22 |
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 the review of client records, the facility failed to document case consultations within the policy and procedure timeframe in four out of six applicable client records. The facility's policy and procedures manual, states all clients will have their treatment reviewed after evaluation and thereafter every sixty days.
Client #2 was admitted on February 24, 2022 and was still active at the time of the inspection. There was one case consultation documented in the client record on February 24, 2022.
Client #4 was admitted on admitted on May 4, 2022 and was still active at the time of the inspection. A case consultation was due on or before July 4, 2022; however, it was not completed as of the time of the inspection.
Client #5 was admitted on March 2, 2022 and was discharged on May 19, 2022. There was one case consultation documented in the client record on March 2, 2022.
Client #6 was admitted on March 9, 2022, 2022 and was discharged on August 8, 2022. There was one case consultation documented in the client record on March 9, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Lead Counselor will train all clinical staff on the completion and timeliness of case consultations, how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.15.22 |
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 an aftercare plan in one out of three discharged records reviewed.
Client #5 was admitted on March 2, 2022 and was discharged on May 19, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will train all clinical staff on the completion and timeliness of Aftercare Plans, how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.8.22. |
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 three out of three discharged records reviewed.
Client #5 was admitted on March 2, 2022 and was discharged on May 19, 2022.
Client #6 was admitted on March 9, 2022 and was discharged on August 8, 2022.
Client #7 was admitted on March 30, 2022 and was discharged on May 25, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will train all clinical staff on the completion and timeliness of discharge summaries, how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.8.22 |
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 provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed.
Client #5 was admitted on March 2, 2022 and was discharged on May 19, 2022.
Client #6 was admitted on March 9, 2022 and was discharged on August 8, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lead Counselor will train all administrative staff who complete follow ups and clinical staff on the completion and timeliness of gathering follow up Information (Follow up contact), how to accomplish this and what the Naaman Center's policy is for the timeliness of this document. The Lead Counselor and Quality Assurance appointee will review charts to verify compliance and will follow up and train accordingly. Compliance will be met by 11.8.22 |