INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14-15, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Malvern Institute, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of staff records and supervision notes on June 14, 2017, the facility failed to ensure that a Counselor Assistant received the required direct observation during the first three months of employment.
Employee #13 was hired as a counselor assistant on 8/22/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
After careful review of all new counselor assistants hired Malvern Institute will ensure that any staff with high school level qualifications will receive 3 months of direct observation by another qualified counselor staff within the facility. The qualified counselor staff will be in the room when the Counselor Assistant performs any clinical duties. Once Direct Observation is completed, after 3 months, the Counselor Assistant will go to close supervision for 9 more months.
In this specific staff case, we did file an exception on 6/22/17. This staff has a great deal of education and experience just an unrelated degree. He is working towards his Masters in Counseling and will graduate in 2019. This staff will begin direct observation immediately and continue for 3 months with the clinical supervisor. If Malvern's exception is granted then direct observation would no longer be necessary. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report (SRFSR), the facility failed to ensure that the staff-to-client ratio remained at or below one primary care staff person for every seven clients.
On Tuesday, May 9, 2017 from 1 a.m. to 4 a.m. there were two primary care staff on the detox unit schedule with the client census reported at 18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Malvern Institute will ensure that it always has a 1:7 ratio of primary staff to detox patients. The Chief Clinical Officer, educated the Assistant Director of Nursing and the Executive Director at the Willow Grove Inpatient site the absolute need to be in compliance with this ratio to ensure patient safety. There will be a nurse or another primary staff on duty at all times to achieve this ratio.
In this case a nursing staff had called out sick. Other nurses were called to replace her but none were available. If a situation like this occurs again we will be able to pull a counselor from the clinical team to be assigned to detox for the hours needed. |