INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically Buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on October 15-17, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. 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 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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.
|
Observations
Based on a review of employee personnel and supervision records, the facility failed to document the required period of direct observation for one counselor assistant.
The findings include:
The personnel records of four counselor assistants were reviewed on October 15, 2014. The facility failed to document the correct amount of supervision for one out of four counselor assistants reviewed, specifically employee # 9.
The counselor assistant represented in record # 9 was hired as an aid on January 7, 2014 and promoted to the position of counselor assistant on June 30, 2014. Employee #9 is a high school level counselor assistant and is therefore required to have three months of documented direct observation and nine months of close supervision. As of the date of inspection, employee #9 has only 1 month and 11 days of direct observation, documented from July 7, 2014 through August 18, 2014. From August 25, 2014 to current, the employee has only received close supervision per the documented supervision notes.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director/Supervisors were unaware of the requirement that 3 months of direct supervision is needed for High School level counselor assistants.
The Clinical Director and Clinical Supervisors were educated on this requirement and now fully understand the different levels of supervision needed for counselor assistants depending on their educational background.
The Executive Director will conduct monthly checks of the Clinical Director and Supervisors supervision notes for all counselor assistants to be sure this 3 months of direct supervision is occurring.
To address the current assistant counselor who only had just over a month of direct supervision...the clinical director will do direct supervision with this assistant counselor for 60 days from 11/1/14-1/1/15. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on an inspection of the physical plant, the facility failed to ensure the hot water temperature did not exceed 120 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on October 17, 2014 from approximately 8:40 - 10:20 AM. During the physical plant inspection, it was noted that the hot water temperature registered at 140 degrees Fahrenheit in the single occupant bathroom located in the basement; 138 degrees Fahrenheit in the bathroom adjacent to suite 273 A; and 141 degrees Fahrenheit in the bathroom adjacent to suite 168 A.
The findings were reviewed with facility staff during the physical plant inspection.
|
Plan of Correction
Facilities staff was re educated on the requirement that all bathroom water temperatures cannot exceed 120 degrees.
Upon assessment is was determined, by facilities staff, that the temperature needed to be lowered on the hot water heater affecting the bathrooms cited.
Facilities staff amended the issue immediately.
New thermometers were purchased to better monitor the bathroom water temperatures.
Facilities staff will perform weekly spot checks of water temperatures in randomly selected bedrooms and document the temperatures for 3 months.
Facilities staff will also conduct monthly checks of the water heaters to be sure this does not happen again. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
Based on a review of inpatient client records, the facility failed to document treatment plans to include proposed types of support services in three of ten client records reviewed.
The findings include:
Ten client records were reviewed for comprehensive treatment plans on October 16-17, 2014. The treatment plans were to include the proposed type of support services. The facility failed to document treatment plans that included the proposed type of support service in client records 5, 6, and 7.
The comprehensive treatment plan for client #5 was documented on October 15, 2014; however it did not include a proposed type of support service for client #5.
The comprehensive treatment plan for client #6 was documented on October 13, 2014; however it did not include a proposed type of support service for client #6.
The comprehensive treatment plan for client #7 was documented on May 27, 2014; however it did not include a proposed type of support service for client #7.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The counselors will be re trained on the process and development of treatment plans focusing on support services for the patient.
This education will be documented.
The Clinical Director will do chart checks to be sure support services are discussed with patients and documented on their comprehensive treatment plans. |
709.53(a) LICENSURE Complete Client Record
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:
|
Observations
Based on the review of inpatient client records, the facility failed to document a complete client record to include verification that work done by the client is an integral part of treatment.
The findings include:
Ten inpatient client records were reviewed on October 15-17, 2014. Three of those clients' records were required to include verification that work done by the client is an integral part of treatment. The facility failed to document the connection between the clients' chores and their treatment in three out of three inpatient client records, specifically client records # 4, 5, and 6.
A board outlining the daily kitchen chores/duties for active inpatient clients is posted in the dining area of the facility. These names were compared with the corresponding clients' records to determine if the work was an integral part of treatment.
Client #4 was listed on the board for kitchen duties on 10/16/14 to prepare lunch. The comprehensive treatment plan for client #4 was documented on October 15, 2014; however, there was no documentation of a work therapy assignment for client #4.
Client #5 was listed on the board for house duties on 10/16/14 to do dishes for dinner. The comprehensive treatment plan for client #5 was documented on October 15, 2014; however, there was no documentation of a work therapy assignment for client #5.
Client #6 was listed on the board for house chores on 10/16/14 to do dishes for lunch and dinner. The comprehensive treatment plan for client #6 was documented on October 13, 2014; however, there was no documentation of a work therapy assignment for client #6.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The counselors will be re educated in the process and development of treatment plans. On any of their patients, that may be involved in work therapy at Malvern Institute, it will be reflected on the patients comprehensive treatment plan.
Patients involved in work therapy will be educated by their counselor as to why work therapy is an integral part of their treatment.
The work therapy and treatment planning policies were updated to reflect the change.
The Clinical Director will do chart checks on a regular basis to ensure that work therapy is part of the treatment planning process and development. |