INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1-2, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Marworth 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
During a review of twelve personnel records, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation. Staff #11 was hired on April 12, 2004 as a Transport Specialist and did not have their CPR certification and first aid training. While transporting clients, Staff #11 was the only staff during the transport. Staff #12 was hired on May 4, 2015 as a Transport Specialist and did not have their CPR certification and first aid training. While transporting clients, Staff #12 was the only staff during the transport. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Drivers will complete CPR and first aid training by August 1, 2022 through either the American Red Cross or Geisinger.
Copies of certifications will be kept on-site at Marworth and maintained by the Manager of Inpatient Addiction Access as well as Marworth's Administrative assistant.
Drivers will be reassessed every 6 months to ensure all pertinent trainings and certifications are up to date.
Updates will be presented at both the Leadership meetings, and Performance Improvement meetings. |
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
Based on a review of seven client records, the project failed to have a complete client record in two out of three applicable clients that included information relative to the client's involvement with the project, including follow-up information. Client #12 was admitted on August 20, 2021 and was discharged on September 12, 2021. Client #12 did not have documentation of follow-up information in the client record.Client #14 was admitted on November 5, 2021 and was discharged on November 29, 2021. Client #14 did not have documentation of follow-up information in the client record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Facility Director updated the HIM Department lead in a meeting held 6/30/22 about discharge follow up documentation to include sending follow-up discharge surveys for both Routine and Non-Routine Discharges within 90 days of discharge.
* Non-Routine Discharge patients will indicate on their Non-Routine Discharge form that they consent to have follow-up from Geisinger Marworth.
i. The HIM workflow was updated to include running a report from EMR-TIER each month identifying those patients who have routinely and non-routinely discharged within 90 days.
ii. Those patients who non-routinely discharged and declined to have follow-up from Geisinger Marworth will have a counseling note placed in the EMR by a member of HIM team to indicate the patient declined follow-up.
iii. Those patients who are routine discharges and the non-routine but consented to Geisinger Marworth follow up will receive a letter in the mail along with a 90 Day Follow up Discharge Survey to complete and return. Subsequently, a counseling note will be placed in the EMR by a member of the HIM team indicating the 90 day follow up discharge survey was sent to patient.
iv. When a discharged patient returns a discharge survey, the survey will be reviewed by the Director of Counseling and feedback regarding program improvements will be discussed at the next monthly Leadership meeting.
a. Director of Counseling will complete a monthly audit of 30 discharge charts beginning 7/5/22 that discharged 90 days prior to confirm compliance with discharge follow up procedure.
b. Director of Counseling will conduct the audits starting 7/5/22 and continue
until there have been 3 consecutive months of 100% compliance with the discharge follow up procedure.
c. Director of Counseling will report findings of each monthly audit at the PI meeting beginning 7/19/22.
d. Documentation of results will be placed in an electronic shared data base for HIM department lead or Designee to reference. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on the review of client records, the facility failed to document client orientation to project policies in seven out of seven applicable records reviewed.These findings were reviewed with facility staff during the licensing process. This was a repeat citation from a licensing inspection that took place on June 10, 2021.
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Plan of Correction
Facility Director added to the EMR, the Client Orientation Packet form reflecting our telemedicine model to include project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation. Patients will verbalize and understanding of the program and will then sign off on the same.
The process of obtaining an electronically signed copy of the orientation packet was reviewed and revised to reflect telemedicine model on 6/30/22.
i. Our orientation packet included, project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation
ii. Approval for revised procedure to obtain an electronic signature on the orientation packet form was completed on 6/30/22 by Facility Director and Counseling Director
a. Counseling Director supplied education to Office Coordinator /designee and outpatient counselors/designee on 6/30/22.
b. Client orientation form will be signed electronically in the EMR by all active clients and all new clients beginning 7/5/2022.
a.Counseling Director to perform audits.
b.Review 30 active client charts to ensure orientation has been electronically signed and documented in medical record.
c.Audit will begin on 8/1/22 and will continue until 3 consecutive months of 100% compliance are achieved.
i. Results will be compiled and distributed at our monthly PI meeting beginning, 8/19/22 with documentation of audit.
a.Results to go to Office Coordinator, Outpatient Counselors / designee for improvement by Counseling Director.
b.Results communicated in PI meeting by Counseling Director verbally.
i. Documentation of results will be placed in an electronic shared data base for Office Coordinator & Outpatient Counselors/ Designee to reference. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on the review of client records, the facility failed to document client orientation to hours of operation in seven out of seven applicable records reviewed.These findings were reviewed with facility staff during the licensing process. This was a repeat citation from a licensing inspection that took place on June 10, 2021.
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Plan of Correction
Facility Director added to the EMR, the Client Orientation Packet form reflecting our telemedicine model to include project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation. Patients will verbalize and understanding of the program and will then sign off on the same.
The process of obtaining an electronically signed copy of the orientation packet was reviewed and revised to reflect telemedicine model on 6/30/22.
i. Our orientation packet form included, project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation
ii. Approval for revised procedure to obtain an electronic signature on the orientation packet form was completed on 6/30/22 by Facility Director and Counseling Director
a. Counseling Director supplied education to Office Coordinator /designee and outpatient counselors/designee on 6/30/22.
b. Client orientation packet form will be signed electronically in the EMR by all active clients and all new clients beginning 7/5/2022.
c. Counseling Director to perform audits.
d. Review 30 active client charts to ensure orientation has been electronically signed and documented in medical record.
e. Audit will begin on 8/1/22 and will continue until 3 consecutive months of 100% compliance are achieved.
f. Results will be compiled and distributed at our monthly PI meeting beginning, 8/19/22 with documentation of audit.
g. Results to go to Office Coordinator, Outpatient Counselors / designee for improvement by Counseling Director.
h. Results communicated in PI meeting by Counseling Director verbally.
i. Documentation of results will be placed in an electronic shared data base for Office Coordinator & Outpatient Counselors/ Designee to reference. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on the review of client records, the facility failed to document client orientation to the fee schedule in seven out of seven applicable records reviewed.These findings were reviewed with facility staff during the licensing process. This was a repeat citation from a licensing inspection that took place on June 10, 2021.
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Plan of Correction
Facility Director added to the EMR, the Client Orientation Packet form reflecting our telemedicine model to include project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation.
The process of obtaining an electronically signed copy of the orientation packet form was reviewed and revised to reflect telemedicine model on 6/30/22.
i. Our orientation packet included, project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation
ii. Approval of the orientation packet form was completed on 6/30/2022 by Facility Director and Counseling Director
a. Counseling Director supplied education to Office Coordinator /designee and outpatient counselors/designee on 6/30/22.
b. Client orientation packet form will be electronically signed in the EMR by all active clients and all new clients beginning 7/5/2022.
c. Counseling Director to perform audits.
d. Review 30 active client charts to ensure orientation has been electronically signed in
the EMR and documented in medical
record.
e. Audit will begin on 8/1/22 and will continue until 3 consecutive months of 100% compliance are achieved.
f. Results will be compiled and distributed at our monthly PI meeting beginning, 8/19/22 with documentation of audit.
g. Results to go to Office Coordinator, Outpatient Counselors / designee for improvement by Counseling Director.
h. Results communicated in the monthly PI meeting by Counseling Director verbally.
i. Documentation of results will be placed in an electronic shared data base for Office Coordinator & Outpatient Counselors/ Designee to reference. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on the review of client records, the facility failed to document client orientation to services provided in seven out of seven applicable records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director added to the EMR, the Client Orientation Packet form reflecting our telemedicine model to include project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation. The process of obtaining an electronically signed copy of the orientation packet form was reviewed and revised to reflect telemedicine model on 6/30/22.
i. Our orientation packet included, project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation
ii. Approval of the orientation packet form was completed on 6/30/2022 by Facility Director and Counseling Director
a.Counseling Director supplied education to Office Coordinator /designee and outpatient counselors/designee on 6/30/22.
b. Client orientation packet form will be electronically signed in the EMR to all active clients and all new clients beginning 7/5/2022.
c. Counseling Director to perform audits.
d. Review 30 active client charts to ensure orientation has been electronically signed in the EMR and documented in medical record.
e. Audit will begin on 8/1/22 and will continue until 3 consecutive months of 100% compliance are achieved.
f. Results will be compiled and distributed at our monthly PI meeting beginning, 8/19/22 with documentation of audit.
g. Results to go to Office Coordinator, Outpatient Counselors / designee for improvement by Counseling Director.
h. Results communicated in the monthly PI meeting by Counseling Director verbally.
i. Documentation of results will be placed in an electronic shared data base for Office Coordinator & Outpatient Counselors/ Designee to reference. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed. Client #16 was admitted on December 6, 2021 and was current at the time of the inspection. A treatment plan update was completed on March 25, 2022, and the next update was due by May 25, 2022; however, the next treatment plan was not completed until May 31, 2022. Client #19 was admitted on October 25, 2021 and was discharged on January 13, 2022. A treatment plan update was completed on October 27, 2021, and the next update was due by December 27, 2021; however, there was not completed until January 3, 2022. Client #21 was admitted on September 7, 2021 and was discharged on February 28, 2022. A treatment plan update was completed on November 5, 2021, and the next update was due by January 5, 2022; however, was not completed until January 7, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Counseling reviewed with the Outpatient Counseling team the procedure of reviewing and updating all Treatment and rehabilitation plans at least every 60 days on 6/10/22.
a.Counseling Director to perform monthly audits beginning 7/1/22.
b. Review 30 active charts to ensure the policy on review of the Treatment and rehabilitation plans are being documented at least every 60 days.
c. The results will be compiled and distributed at our monthly PI meeting beginning 7/19/22 with documentation of the audit.
d. Results go to the Outpatient Counselor/designee for Improvement by Counseling Director.
e. Results communicated in the monthly PI meeting by Counseling Director verbally.
f. Documentation of results will be placed in an electronic shared data base for Outpatient Counselors /Designee to reference. |
709.93(a)(11) LICENSURE Client records
709.93. 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
Based on a review of seven client records, the project failed to have a complete client record in one out of two applicable clients that included information relative to the client's involvement with the project, including follow-up information. Client #19 was admitted on October 25, 2021 and was discharged on January 13, 2022. Client #19 did not have documentation of follow-up information in the client record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Facility Director updated the HIM Department lead in a meeting held 6/30/22 about discharge follow up documentation to include sending follow-up discharge surveys for both Routine and Non-Routine Discharges within 90 days of discharge. * Non-Routine Discharge patients will indicate on their Non-Routine Discharge form that they consent to have follow-up from Geisinger Marworth.
i.The HIM workflow was updated to include running a report from EMR-TIER each month and identifying those patients who have routinely and non-routinely discharged.
ii. Those patients who non-routinely discharged and declined to have follow-up from Geisinger Marworth will have a counseling note placed in the EMR by a member of HIM team to indicate the patient declined follow-up.
iii. Those patients who are routine discharges and the non-routine but consented to Geisinger Marworth follow up, will receive a letter in the mail along with a 90 Day Follow up Discharge Survey to complete and return.
Subsequently, a counseling note will be placed in the EMR by a the HIM team indicating the 90 day follow up discharge survey was sent to patient.
iv. When a discharged patient returns a discharge survey, the survey will be reviewed by the Director of Counseling and Feedback regarding program improvements will be discussed at the next monthly Leadership meeting.
v. During follow-up the client will be assessed as to how he/she is progressing and if any further services are needed. If additional services are needed, the client will be referred to these services as deemed appropriate.
a. Director of Counseling will complete a monthly audit of 30 discharge charts beginning 7/5/22 that discharged 90 days prior to confirm compliance with discharge follow up procedure.
b. Director of Counseling will conduct the audits starting 7/5/22 and continue until there have been 3 consecutive months of 100% compliance with the discharge follow up procedure.
c. Director of Counseling will report findings of each monthly audit at the PI meeting beginning 7/19/22.
d. Documentation of results will be placed in an electronic shared data base for HIM department lead or Designee to reference. |