INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 2019 through July 3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(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
The facility failed to ensure that 10 of 20 reviewed employees received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe. Employee #9 was hired as a counselor on August 8, 2017 and was due to have HIV/AIDS training and TB/STD training no later than August 8, 2018. The HIV/AIDS training was completed on October 17, 2018 and the TB/STD training was completed on October 25, 2018.Employee #12 was hired as a clinical aide on February 14, 2017 and was due to have HIV/AIDS training and TB/STD training no later than February 14, 2019. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee #13 was hired as a clinical aide on January 25, 2016 and was due to have HIV/AIDS training and TB/STD training no later than January 25, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.Employee #14 was hired as a clinical aide on September 27, 2016 and was due to have HIV/AIDS training and TB/STD training no later than September 27, 2018. There was no documentation of the completion of the TB/STD training as of the date of the inspection.Employee #15 was hired as a clinical aide on July 25, 2016 and was due to have HIV/AIDS training and TB/STD training no later than July 25, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.Employee #16 was hired as a clinical aide on August 2, 2016 and was due to have HIV/AIDS training and TB/STD training no later than August 2, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.Employee #17 was hired as a lead clinical aide on July 18, 2016 and was due to have HIV/AIDS training and TB/STD training no later than July 18, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.Employee #18 was hired as a financial counselor on May 31, 2016 and was due to have HIV/AIDS training and TB/STD training no later than May 31, 2018. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.Employee #19 was hired as an admissions counselor on August 31, 2016 and was due to have HIV/AIDS training and TB/STD training no later than August 31, 2018. There was no documentation of the completion of the TB/STD trainings as of the date of the inspection.Employee #20 was hired as a um coordinator on September 6, 2016 and was due to have HIV/AIDS training and TB/STD training no later than September 6, 2018. There was no documentation of the completion of the TB/STD trainings as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The HR manager will seek out programs that offer the 6 hour HIV/AIDS training as well as the 4 hour TB/STD training. The 10 staff members deficient in this will be signed up for the training at the earliest possible opening. The HR manager will monitor new employee charts for to ensure they meet the timelines for training per regulation standards. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to develop, and make available to the public, their 2018 annual report. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An annual report which includes the names of the members of the board will be made available to the public. The divisional director of business development will publish the completion and availability of the annual report in a public forum such as a public newspaper. A copy of the publishing will be kept on file for review. The Compliance Manager will review a copy of this document annually to ensure adherence to the regulation. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Corporate Risk Manager and the Compliance Manager will assemble a team that reviews Malvern's policies and procedures annually. The team will then present this to the Project Director to sign off annually upon completion. The Corporate Risk Manager and Compliance Manager will monitor policy reviews and will ensure its completion between November 1st and December 31 annually. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that the personnel records contained documentation of an annual written individual performance evaluation in one of four employee records reviewed.Employee # 1 was hired as the project director on June 27, 2017. There was no documentation of an annual written individual performance evaluation completed for the review year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employees #1 had her written individual performance evaluation completed. The HR team will continue to manage employee files and ensure that all employees receive an annual performance evaluation. The HR manager will perform annual audits and send out reminders to deficient staff members to ensure compliance with the regulation. |
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
The facility failed to ensure that all hard copy patient records were kept within locked storage containers as multiple discharged clients' records were found unsecured in the medical assistant's office.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All charts were removed from the medical assistant's office. Client records will be kept within a locked filing cabinet in the nurses's station. The medical assistant will only have access to the charts during the review process. When the review is done, the charts will be returned to nursing or forwarded to the medical records department where it will be stored behind locked doors. The medical records coordinator and the compliance manager will monitor the flow of charts to ensure compliance. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
The facility failed to document the countersignature of either the medical director or a narcotic treatment physician on records pertaining to functions performed by the physician assistant on one of three applicable client records reviewed.Client #1 was admitted to the inpatient nonhospital detoxification level of care on June 27, 2019 and was still active at the time of the inspection. The client's record contained documentation of a physical examination conducted by the physician assistant on June 28, 2019; however, the physical examination was not countersigned by a physician.This is a repeat citation from the 7/27/2018 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The physicians will follow up and countersign all records completed by physician assistants. This will be tracked by the Director of Nursing and the Medical Clerk through monthly chart checks. |
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
The facility failed to verify the individual's identity, including name, address and date of birth, prior to the administration of a narcotic agent in one of five applicable client records.Client # 1 was admitted to the inpatient nonhospital detoxification level of care on June 27, 2019 and was still active at the time of the inspection.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Malvern institute will verify the identity of each client prior to the administration of a narcotic agent. When identification is not readily available Malvern Institute will follow the guidelines laid out in licensing alert 01-2018 to verify the client's identity. The Director of Admissions and Utilization Management will train admissions staff on these guidelines and will conduct periodic chart checks to ensure compliance. Progress will be discussed at the monthly performance enhancement meetings. |
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
The facility failed to provide documentation that the narcotic treatment physician conducted the initial face-to-face with the client prior to the administration of a narcotic drug. Additionally, the required documentation of the client's 1-year history of physiological dependence and current dependency was not completed by the physician in one of three applicable client records reviewed. Client #1 was admitted on June 27, 2019 and was still active at the time of the inspection. The facility began administering buprenorphine to the client on June 30, 2019. The initial face-to-face meeting was conducted by the Certified Registered Nurse Practitioner and not the narcotic physician. Additionally, the documentation of the client's current dependence and 1-year history was completed by the CRNP on June 29, 2018. At the time of the inspection, the facility did not have, nor have they applied for, a federal exemption to allow Physician Assistants and Certified Registered Nurse Practitioners to make the 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.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, a narcotic treatment physician will conduct the initial face to face with the client before administering a narcotic drug. Malvern will apply for a waiver for the CRNP on staff. Until the waiver is granted only the physician will conduct the face to face. The Director of Nursing will monitor patient charts to ensure Malvern is compliant with this process. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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
The facility failed to provide follow-up information in the client's complete record in three of four applicable client records reviewed.Client #12 was admitted into the inpatient nonhospital residential level of care on July 22, 2018 and was discharged on July 31, 2018.Client #14 was admitted into the inpatient nonhospital residential level of care on December 31, 2018 and was discharged on January 23, 2019.Client #15 was admitted into the inpatient nonhospital residential level of care on September 9, 2018 and was discharged on September 26, 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Utilization Management Coordinators will be trained by their Manager to ensure calls are made and letters are sent to clients when calls are not feasible. The Compliance Manager will periodically review the follow up log to ensure compliance. |