INITIAL COMMENTS
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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 1, an abbreviated off-site inspection, conducted on May 11, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Malvern Institute for Psychiatric and Alcoholic Studies, Inc. 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:
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 4, 2021 by staff from the Bureau of Program Licensure. Part 2 consisted of a physical plant inspection and client record reviews.
Based on the findings of Part 2, an on-sitelicensure renewal inspection, Malvern Institute for Psychiatric and Alcoholic Studies, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of the Staffing Facility Requirements Summary Report and personnel records, the facility failed to ensure that employee #6 received the minimum of six hours of HIV/AIDS training and four hours of TB/STD training within the regulatory timeframe.
Employee # 1 was hired as a counselor on May 1, 2019 and was due to have HIV/AIDS and TB/STD training no later than May 1, 2020; however, there was no documentation of the completion of the HIV/AIDS training or the TB/STD training on file.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: responded to during previous survey.
Identification of Failure
Employee # 1 hired on May 1, 2019 was scheduled to attend HIV/AIDS/TB/STD training on March 25. Due to the COVID-19 pandemic all facility and contracted training were cancelled for the months of March-June. This documentation was provided during the survey.
Action
The Director of HR and the Director of Quality reviewed and approved Malvern Institutes training policy 8000.065.
Employee #1 is scheduled for the next available training in the month of July.
Monitoring
Upon hire all staff members are assigned mandatory training with a timeframe for completion based on their job description. The Human Resources Department maintains a tracking grid to ensure training are scheduled and completed within the required timeframe.
The HR department will send training requirement reminders to each staff member and their supervisor prior to required deadlines.
Malvern Institute will identify a staff member to be trained in the DDAP core curriculum of HIV/AIDS/STD/TB in the case the facility is unable to obtain a contracted trainer to meet the facility needs.
Compliance rates with staff training requirements will be reported to the Director of HR monthly to ensure compliance. Monthly reporting of staff training compliance will continue until Malvern Institute has reached 100% compliance for 4 months. June 1, 2020
Completion Date:
06/01/2020
Status:
Approved
Date:
05/20/20 |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on March 4, 2021, the facility failed to keep the facilty in good repair at all times for the safety and well-being of residents, employees and visitors. The following issues were found.
A section of fascia was missing from the second story of the building above the kitchen emergency exit door.
An office on the second floor, near the female residential wing, was observed to have two cracked windows, and one of these windows was taped around it's perimeter.
These findings were reviewed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: The fascia board, which had been damaged during the wind storm the day prior to the survey.
Action: Fascia was replaced on 3/12/2021.
Identification of Failure: Two windows identified as being cracked around the perimeter.
Plan of Correction: Materials were ordered for the two cracked windows on the second floor near the female residential wing. The cracks have been mitigated and the scheduled date of replacement is 5/5/2021
Monitoring: Facility building and grounds are part of the formal facility inspections which occur at least quarterly. Findings are reported to the facility Safety Committee for monitoring. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on March 4, 2021, the facility failed to maintaing counseling area furnishings in good repair.
Furniture was observed to be torn and/or worn bare in two second floor offices. The lead counselor's office had an office chair that was worn bare. The first office inside the male inpatient hall had furniture that was worn bare and ripped.
These findings were discussed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: Torn/worn furniture located in Lead Counselor's office and in the first office inside the male inpatient hall on the second floor.
Action: Furniture was replaced 3/12/2021.
Monitoring: Furniture condition will be added to the facility inspections which occur at least quarterly. Findings are reported to the facility Safety Committee for monitoring. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on March 4, 2021, the facility failed to ensure privacy so that counseling could not be seen or heard outside of the counseling room.
The first floor group room was observed to have a camera installed in the cornerof the room. Also, during the inspection, the group being conducted could be heard from the hallway.
The basement group room door had a window that did not have a covering and group participants could be observed in the room. There is also a camera located in this group room.
These findings were discussed with the facility.
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Plan of Correction
Plan of Correction: At this time Malvern Treatment Centers has requested an exception for the usage of camera's in our group spaces due to the facility's treatment of our Co-Occurring Dual Diagnosis patients. A response is expected 4/6/2021.
The Director of IT will work with the camera vendor to disable the cameras in the in process group spaces by 4/30/2021.
It was discussed at the time of the survey that treatment activities could not be viewed from the window in the door. At the time of the survey and prior to the surveyors leaving the building, the window was covered during the survey to ensure privacy.
Privacy coverings will be added to the facility inspection sheet to ensure all treatment activities remain private. Facility inspections, completed and monitored by the Director of Plant Operations, occur at least Quarterly and findings are reported to the facility Safety Committee for monitoring.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on March 4, 2021, the facility failed to ensure a bathroom had hot and cold water under pressure.
Water did not come out of the faucet when the hot water handle was turned on in the first floor bathroom labeled as the Admit Patient Bathroom.
This finding was discussed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: Water did not come out of the faucet when the hot water handle was turned on in the first floor bathroom labeled as the Admit Patient Bathroom.
Action: Repair was completed on 3/4/2021
Monitoring: Hot water issues are to be reported to facilities management immediately. Temperature checks will be added to the facility building and grounds formal facility inspections which occur at least quarterly. Findings are reported to the facility Safety Committee for monitoring. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on March 4, 2021, the facility failed to have slip-resistant surfaces in all bathtubs and showers.
The following client bathrooms did not have slip-resistant surfaces in their showers: Room #'s 1E01, 1E02, 1S02A, 1S04A, 3S03, 3S05, 3S06
This finding was discussed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: The following client bathrooms did not have slip-resistant surfaces in their showers: Room #'s 1E01, 1E02, 1S02A, 1S04A, 3S03, 3S05, 3S06
Action: Slip resistant material was installed to the identified showers on 3/4/2021.
Monitoring: Facility building and grounds are part of the formal facility inspections which occur at least quarterly. Findings are reported to the facility Safety Committee for monitoring. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on March 4, 2021, the facility failed to have ventilation in one bathroom.
The bathroom connected to room # 212 did not have a window and did not have a functioning exhaust fan.
This finding was reviewed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: The bathroom connected to room # 212 did not have a window and did not have a functioning exhaust fan.
Action: Exhaust fan was replaced 3/4/2021
Monitoring: Facility building and grounds are part of the formal facility inspections which occur at least quarterly. Findings are reported to the facility Safety Committee for monitoring. |
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
Based on a review of the facility's client records on March 4, 2021, the facility failed to document when the witness signed or when the client signed the release form. The form only had one spot for a date to cover both signatures.
This finding was discussed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: The consent forms lacked two independent spots for dates to cover both the client and witness signatures.
Action: The Director of Clinical Services will oversee and monitor the consent form update to include the date the patient signed the consent. At the time of the signature the counselor/witness will ensure the patient includes the date.
Monitoring: Monitoring of consent forms is part of the facility monthly quality audits. The Director of Clinical Services will monitor quality audits to ensure both date lines are included on all consents. Monitoring will begin during the monthly chart audits in April 2021. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's client records on March 4, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
A client receiving care or treatment under section 7 of the act (71 P.S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
This finding was discussed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: Based on a review of the facility's client records on March 4, 2021, the facility failed to include the following verbiage on the client rights form that the client receives. A client receiving care or treatment under section 7 of the act (71 P.S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
Action: The following verbiage was added to the facility policy Admin 113 and the patient handbook.
'A client receiving care or treatment under section 7 of the act (71 P.S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.'
All patients receive the handbook and patient bill of rights upon admission. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's client records on March 4, 2021, the facility failed to state that the facility may not discriminate in the provison of services on the basis of creed, ethnicity or marital status on the client rights that the residents receive upon admission.
This finding was discussed with the facility.
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Plan of Correction
Plan of Correction:
Identification of Failure: The facility failed to state that the facility may not discriminate in the provision of services on the basis of creed, ethnicity or marital status on the client rights that the residents receive upon admission.
Action: The following verbiage was added to the facility policy Admin 113 and the patient handbook.
"The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion."
Monitoring: All patients receive the handbook and patient bill of rights upon admission.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the facility's client records on March 4, 2021, the facility failed to include the following verbiage on the client rights form that the client receives upon admission.
Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
This finding was reviewed with facility staff.
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Plan of Correction
Plan of Correction:
Identification of Failure: The facility failed to include the following verbiage on the client rights form that the client receives upon admission.
"Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
Action: The following verbiage was added to the facility policy Admin 113 and the patient handbook.
"Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
Monitoring: All patients receive the handbook and patient bill of rights upon admission. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the facility's client records on March 4, 2021, the facility failed to include the following verbiage on the client rights form that the client receives upon admission.
Clients have the right to appeal a decision limiting access to their records to the director.
This finding was discussed with facility staff.
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Plan of Correction
Plan of Correction:
Identification of Failure: The facility failed to include the following verbiage on the client rights form that the client receives upon admission.
"Clients have the right to appeal a decision limiting access to their records to the director."
Action: The following verbiage was added to the facility policy Admin 113 and the patient handbook.
"Clients have the right to appeal a decision limiting access to their records to the director."
Monitoring: All patients receive the handbook and patient bill of rights upon admission. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the facility's client records on March 4, 2021, the facility failed to include the following verbiage on the client rights form that the client receives upon admission.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This finding was discussed with the facility staff.
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Plan of Correction
Plan of Correction:
Identification of Failure: The facility failed to include the following verbiage on the client rights form that the client receives upon admission.
"Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records."
Action: The following verbiage was added to the facility policy Admin 113 and the patient handbook.
"Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records."
Monitoring: All patients receive the handbook and patient bill of rights upon admission. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the facility's client records on March 4, 2021, the facility failed to include the following verbiage on the client rights form that the client receives upon admission.
Clients have the right to submit rebuttal data or memoranda to their own records.
This finding was discussed with facility staff.
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Plan of Correction
Plan of Correction:
Identification of Failure: The facility failed to include the following verbiage on the client rights form that the client receives upon admission.
"Clients have the right to submit rebuttal data or memoranda to their own records."
Action: The following verbiage was added to the facility policy Admin 113 and the patient handbook.
"Clients have the right to submit rebuttal data or memoranda to their own records."
Monitoring: All patients receive the handbook and patient bill of rights upon admission. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of the client records on March 4, 2021, the facility failed to document when the client signed the release form. The forms were not dated when they were signed.
This finding was discussed with facility staff.
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Plan of Correction
Plan of Correction:
Identification of Failure: The consent forms lacked two independent spots for dates to cover both the client and witness signatures.
Action: The Director of Clinical Services will oversee and monitor the consent form update to include the date the patient signed the consent. At the time of the signature the counselor/witness will ensure the patient includes the date.
Monitoring: Monitoring of consent forms is part of the facility monthly quality audits. The Director of Clinical Services will monitor quality audits to ensure both date lines are included on all consents. Monitoring will begin during the monthly chart audits in April 2021. |