INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection monitoring conducted on June 6, 2022 through June 7, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-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:
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client record reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client # 14 was admitted to the inpatient non-hospital activity on May 9, 2022 and was discharged against medical advice on May 17, 2022; however, the emergency contact was not notified of the client ' s discharge at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The counselor for Client # 14 had contacted the emergency contact via a phone conversation but did not document the interaction appropriately.
Action: The counselors and clinical supervisors were re-educated that the EC must be contacted with 12 hours of a patient leaving the facility against medical advice and that the notification must be documented in the patient's chart.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with documenting contact with the emergency contact within 12hrs of a patient leaving the facility against medical advice. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. On June 6, 2022, at approximately 9:30 AM, there was unsecured paper client records in room 201, which was a vacant counseling office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Patient records were left in an open container in a unattended office.
Action: The patient records were removed from the office at the time of the survey and were stored in locked storage containers.
Monitoring: During monthly EOC rounds the Director of PI will monitor the facility for hard copy client records left out in the open and assure that records are secured within locked storage containers. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of fourteen client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on December 28, 2021 and was discharged on January 16, 2022. The release of information form to a public defender was signed and dated by the witness on December 29, 2021, but the form did not document the dated signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: A counselor failed to obtain a signature from a client for the release of information to a public defender.
Action: Counselors were re-educated on the requirement to obtain an informed and voluntary consent, including signature from a client for disclosure of information contained in the client record.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with obtaining signed consent for the release of information contained in the client's record. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of two applicable client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on December 28, 2021 and was administratively discharged on January 16, 2022. There was no documentation in the record that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The electronic medical record did not have a notification that the client has an opportunity to request reconsideration of the facility's decision to terminate treatment.
Action: The electronic medical record termination form has been edited to require the question regarding appeal to be answered before the document can be saved and completed.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance regarding the patient having the opportunity to request reconsideration of a decision terminating treatment. 25 charts will be audited each month with a goal of 100% compliance for 3 months.
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