INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14, 2021 through June 15, 2021 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that all clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of two applicable personnel records reviewed.
Employee # 4 was hired as a clinical supervisor on October 30, 2020 and did not have clinical supervision experience prior to being hired. There was no documentation of a Department approved clinical supervision training on file 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: Employee #4 did not have previous supervisor experience prior to being hired and did not receive clinical supervision training within 6 months from his hire date for the supervisor position.
Action: Employee #4 was scheduled for a core curriculum in clinical supervision program in Pittsburgh, PA for August 23 -27, 2021.
Monitoring: All new hires for clinical supervisor positions will be immediately scheduled upon hire for a core curriculum in clinical supervision if they do not meet the 2 years of supervisor experience requirements. Human resources will monitor and schedule these trainings. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on a physical plant inspection conducted on June 15, 2021, the facility failed to provide a storage area for clothing for each resident in a facility bedroom. Bedroom 1S06 had three client beds available for occupancy and only one storage dresser. Additionally, Bedroom 1S07 had three client beds available for occupancy and only two storage dressers.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Prior to the inspection storage dressers had been removed from the rooms due to damage.
Action: Shelving was added on 6-16-21 to 2 closets in room number 1S06 and One closet in room 1S07. Each closet has 2 new shelves for clothing storage.
Monitoring: Monthly walk-through inspections will occur and findings will be reported in the monthly facility safety committee meetings. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of fourteen client records reviewed.
Client # 7 was admitted to the detox level of care on June 4, 2021 and was discharged on June 9, 2021. A release of information form to a funding source was signed and dated by the client on June 4, 2021 and allowed for the release of discharge summary, medication summary, history and physical exam report, clinical referral packet, initial intake assessment, physician ' s psychiatric evaluation, verbal communications, psychosocial assessment, entire record, nursing assessments, abstract of record, lab/study results, and discharge information/continuing care, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 14 was admitted to the residential level of care on June 9, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on June 4, 2021 and allowed for the release of discharge summary, medication summary, history and physical exam report, clinical referral packet, initial intake assessment, physician ' s psychiatric evaluation, verbal communications, psychosocial assessment, entire record, nursing assessments, abstract of record, lab/study results, and discharge information/continuing care, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The facility had a process to limit the amount of information released per 4 Pa. Code 255.5 (b) but the client's counselor utilized the incorrect form to receive consent.
Action: The Release of Information (ROI) forms were changed on May 26, 2021 in the new electronic medical record (EMR) to limit the amount of information released to government agencies per 4 Pa Code 255.5 (b). Counselors will be re-educated on these limits.
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 ROI. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on an administrative review of the facility's unusual incident reports log, the facility failed to report an event at the facility requiring the presence of police, fire or ambulance personnel to the Department within 3 business days.
On March 31, 2021, April 20, 2021, and April 25, 2021 there were incident reports that documented the presence of police and emergency medical transport; however, there was no documentation that these incidents were reported to the Department within 3 business days.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Although the facility routinely submits reports to DDAP for unusual incidents it failed to report events at the facility requiring the presence of police, fire or ambulance personnel within 3 business days.
Action: The Director of PI or designee will submit all incidents of events at the facility requiring the presence of police, fire or ambulance personnel to the DDAP Incident Tracking Reporting System within 3 business days of an incident.
Monitoring: The Director of PI will review all facility incident reports daily during business days to determine if external reporting is required and will submit incident reports to DDAP as appropriate. Incident reporting is reviewed monthly in the facility PI committee. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to document in the record the verification of the individual's identity, including name, address, date of birth, emergency contact and other identifying data in three of twelve applicable records reviewed.
Patient # 5 was admitted to the detox level of care on June 4, 2021 and was discharged on June 9, 2021. There was no identity verifcation documentation in the record at the time of the inspection.
Patient # 10 was admitted to the residential level of care on April 18, 2021 and was discharged on May 7, 2021. There was no identity verifcation documentation in the record at the time of the inspection.
Patient # 12 was admitted to the residential level of care on June 9, 2021 and was still active at the time of inspection. There was no identity verifcation documentation in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The identified patients did not have a driver's license or other form of identification upon admission to the facility.
Action: As per Licensing Alert 01-21, dated June 16, 2021, Malvern Treatment Centers will no longer be considered a Narcotic Treatment Program starting July 1, 2021 and will, per the Drug Addiction Treatment Act of 2000 (DATA 2000), be considered an "other chemotherapy" program. The facility will develop a form that is signed by the patient to verify identification upon admission to the facility. All policies and procedures have been revised to reflect the changes in the regulatory requirements.
Monitoring: As per Licensing Alert 01-21, dated June 16, 2021, Malvern Treatment Centers will no longer be considered a Narcotic Treatment Program starting July 1, 2021 and will, per the Drug Addiction Treatment Act of 2000 (DATA 2000), be considered an "other chemotherapy" program. The facility will develop a form that is signed by the patient to verify identification upon admission to the facility. All policies and procedures have been revised to reflect the changes in the regulatory requirements. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to provide documentation that the narcotic treatment physician conducted the initial face-to-face with the patient prior to the administration of a maintenance agent in two of twelve applicable patient records reviewed.
Patient # 5 was admitted to the detox level of care on June 4, 2021 and was discharged on June 9, 2021. The certified registered nurse practitioner prescribed the patient's first dose of medication on June 5, 2021. The initial face-to-face meeting with the narcotic treatment physician was conducted and documented on June 7, 2021.
Patient # 12 was admitted to the residential level of care on June 9, 2021 and was still active at the time of inspection. The certified registered nurse practitioner prescribed the patient's first dose of medication on June 5, 2021. The initial face-to-face meeting with the narcotic treatment physician was conducted and documented on June 7, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The facility utilizes the services of CRNP's per federal regulations to support the physicians in the assessment and treatment of patients in our facility and the CRNP had a face-to-face with the clients and documented the physiological dependency time of addiction. Based on a review of patient records, the facility failed to ensure that the face-to-face determination between the narcotic treatment physician and the client occurred prior to the administration of an agent in one of nine applicable patient records reviewed. Additionally, the narcotic treatment physician failed to document that the patient had been physiologically dependent upon a narcotic drug for at least 1 year prior to the administration of a maintenance agent in two of nine applicable patient records reviewed.
Action: As per Licensing Alert 01-21, dated June 16, 2021, Malvern Treatment Centers will no longer be considered a Narcotic Treatment Program starting July 1, 2021 and will, per the Drug Addiction Treatment Act of 2000 (DATA 2000), be considered an "other chemotherapy" program. The facility will continue to have a member of the medical staff assess patients for the appropriateness of medication-assisted treatment. All policies and procedures have been revised to reflect the changes in the regulatory requirements.
Monitoring: As per Licensing Alert 01-21, dated June 16, 2021, Malvern Treatment Centers will no longer be considered a Narcotic Treatment Program starting July 1, 2021 and will, per the Drug Addiction Treatment Act of 2000 (DATA 2000), be considered an "other chemotherapy" program. The facility will continue to have a member of the medical staff assess patients for the appropriateness of medication-assisted treatment. All policies and procedures have been revised to reflect the changes in the regulatory requirements.
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