INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted from June 4 - 8, 2012, by staff from the Division of Drug and Alcohol 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:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based upon the review of employee records, the facility failed to document individual training plans for each employee upon hire.
The findings include:
Fourteen employee records were reviewed for documentation of individual training plans during the on-site inspection that was conducted from June 4-8, 2012. Two of fourteen records, specifically #'s 9 and 11, did not contain documentation of a training plan that was developed with the employee upon their hire.
Employee # 9 was hired on June 20, 2011, and their Individual Training Plan was due upon hire. The record contained a Training Plan that was dated May 5, 2012, but did not contain a Training Plan that was completed upon the employee's hire.
Employee # 11 was hired on August 29, 2011, and their Individual Training Plan was due upon hire. The record contained a Training Plan that was dated May 14, 2012, but did not contain a Training Plan that was completed upon the employee's hire.
The findings were confirmed by the Director of Quality Improvement during the record review.
|
Plan of Correction
Marworth CEO was ignorant of the stipulation for a training plan for new hires. Beginning in July 1, 2012 all new hires will have a training plan in place within 30 days of start date.A "New employee orientation checklist" lists individual training plans as a documentation requirement within the first 30 days of hire.Compliance with the standard will be monitored by the Director of Quality Improvement for Marworth,who collects all new employee checklists for filing in personnel records. Lack of documentation on the checklist results in a follow up meeting by the Director of QI to ensure proper documentation. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and employee records, the facility failed to ensure that each employee completed the minimum number of required training hours annually.
The findings include:
The SRFSR was reviewed during the on-site inspection conduced from June 4 - 8, 2012. As per documentation contained on the SRFSR, the training year runs from July 1st to June 30th.
Eight records requiring documentation of annual training hours were reviewed from June 6 - 8, 2012. One of eight records, specifically # 6, did not contain documentation of the required number of annual training hours for the period of July 1, 2010 to June 30, 2011.
Employee # 6, a counselor, was hired on March 23, 1992. Employee # 6 was required to complete 25 clock hours of training annually. The record contained documentation of 18.3 clock hours of training for the period of July 1, 2010 to June 30, 2011.
The findings were confirmed by the Director of Quality Improvement during the record review.
|
Plan of Correction
the Director of Counseling and the Outpatient Coordinator will monitor training hours compliance on a quarterly basis, in order to insure compliance with training hours within the training year.Actual individual training hours will be tabulated quarterly. Quarterly results of individual training hours will be provided to the Quality Improvement Director for administrative review and individual supervision will be provided to employees lagging in their hours. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based upon a review of employee records, the facility failed to provide documentation to demonstrate that all staff members were instructed in the use of the fire extinguishers upon their employment.
The findings include:
Five employee records requiring documentation of fire extinguisher training were reviewed from June 7 - 8, 2012. Four of five employee records, specifically #'s 9, 10, 11, and 12, did not contain documentation of fire extinguisher training upon employment.
Employee # 9 was hired on June 20, 2011. As of the date of inspection, the record did not include documentation of employee training in the use of fire extinguishers.
Employee # 10 was hired on July 18, 2011. As of the date of inspection, the record did not include documentation of employee training in the use of fire extinguishers.
Employee # 11 was hired on August 29, 2011. As of the date of inspection, the record did not include documentation of employee training in the use of fire extinguishers.
Employee # 12 was hired on September 7, 2011. As of the date of inspection, the record did not include documentation of employee training in the use of fire extinguishers.
The findings were confirmed by the Director of Quality Improvement during the employee record review.
|
Plan of Correction
As acknowledge in exit conference, corrective action was in place at time of survey. Corrective action included providing the documentation that fire extinguisher training occured during employee orientation. Director of Maintenance is the responsible party for ensuring compliance.
Documentation will be sent to the Director of Quality Improvment who will monitor compliance with this training.
Employees 9,10, 11, 12 will be trained by July 13, 2012 by Director of Maintenance with documentation placed in their personnel files. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based upon a review of employee records, the facility failed to provide documentation to demonstrate that all personnel on all shifts were trained upon employment to perform assigned tasks during emergencies.
The findings include:
Five employee records requiring documentation of emergency training were reviewed from June 7 - 8, 2012. Four of five employee records, specifically # ' s 9, 10, 11, and 12, did not contain documentation of emergency training upon employment.
Employee # 9 was hired on June 20, 2011. As of the date of inspection, the record did not include documentation of emergency training.
Employee # 10 was hired on July 18, 2011. As of the date of inspection, the record did not include documentation of emergency training.
Employee # 11 was hired on August 29, 2011. As of the date of inspection, the record did not include documentation of emergency training.
Employee # 12 was hired on September 7, 2011. As of the date of inspection, the record did not include documentation of emergency training.
The findings were confirmed by the Director of Quality Improvement during the employee record review.
|
Plan of Correction
Emergency preparedness training is the responsibility of department managers at Marworth. All employees are oriented within the first 7 days of employment. New employee orientation check list has been developed and implemented to reflect this training. The completed employee orientation check list comes to the Director of Quality Improvement to be filed in the employee personnel file.
Employees 9,10,11,12 will receive training on emergency preparedness by July 13, 2012 by their department managers. |
709.81(a)(3) LICENSURE Intake and admission
709.81. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
|
Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual, the facility failed to develop a written plan providing for intake and admission, which included requirements for completion of treatment from the client's perspective.
The findings include:
The P&P Manual was reviewed during the on-site inspection that was conducted from June 4-8, 2012.
Policy number 10.154 is titled, "Discharge Categories" and included the following language:
"A. Routine Discharge
A routine discharge occurs when a patient has completed treatment at this level of care and discharge criteria are met (ASAM Discharge Criteria). A routine discharge may result in continuing care at an intensive outpatient program (Level II), an outpatient program (Level I), or a longer term care environment, i.e. a halfway house."
Policy number 10.116 is titled, "ASAM Patient Placement Criteria" and included the following language:
"Policy: It is the policy of Marworth to utilize the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in all levels of the treatment program.
Procedure: 4. At the time of discharge, the Primary Counselor uses the ASAM "Discharge / Referral Criteria" (Attachment 3 of 3) as the patient is considered eligible for discharge to a different level of care. The counselor presents these criteria at Multidisciplinary Team Meeting."
As written, the policies failed to provide specific requirements for completion of treatment from the client's perspective.
The findings were reviewed with the Project Director during the P&P review.
|
Plan of Correction
Criteria for completion of treatment for Partial hospital level of care was developed on July 6, 2012 by a multi-disciplinary team comprising the Outpatient Coordinator, Director of Counseling and Medical Director and will come before a special meeting of the Leadership committee of Marworth for review and approval on or before July 13, 2012. Once approved, the Criteria will become part of the Written Plan and will be posted on the patient bulletin board. |
709.62(a)(3) LICENSURE Completion Requirements
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
|
Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual, the facility failed to develop a written plan providing for intake and admission, which included requirements for completion of treatment from the client's perspective.
The findings include:
The P&P Manual was reviewed during the on-site inspection that was conducted from June 4-8, 2012.
Policy number 10.154 is titled, "Discharge Categories" and included the following language:
"A. Routine Discharge
A routine discharge occurs when a patient has completed treatment at this level of care and discharge criteria are met (ASAM Discharge Criteria). A routine discharge may result in continuing care at an intensive outpatient program (Level II), an outpatient program (Level I), or a longer term care environment, i.e. a halfway house."
Policy number 10.116 is titled, "ASAM Patient Placement Criteria" and included the following language:
"Policy: It is the policy of Marworth to utilize the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in all levels of the treatment program.
Procedure: 4. At the time of discharge, the Primary Counselor uses the ASAM " Discharge / Referral Criteria " (Attachment 3 of 3) as the patient is considered eligible for discharge to a different level of care. The counselor presents these criteria at Multidisciplinary Team Meeting."
As written, the policies failed to provide specific requirements for completion of treatment from the client's perspective.
The findings were reviewed with the Project Director during the P&P review.
|
Plan of Correction
Criteria for completion of treatment for Detoxification level of care was developed on July 6, 2012 by a multi-disciplinary team comprising the Outpatient Coordinator, Director of Counseling and Medical Director and will come before a special meeting of the Leadership committee of Marworth for review and approval on or before July 13, 2012. Once approved, the Criteria will become part of the Written Plan and will be posted on the patient bulletin board. |
709.51(a)(3) LICENSURE Tx Completion Requirements
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
|
Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual, the facility failed to develop a written plan providing for intake and admission, which included requirements for completion of treatment from the client's perspective.
The findings include:
The P&P Manual was reviewed during the on-site inspection that was conducted from June 4-8, 2012.
Policy number 10.154 is titled, "Discharge Categories" and included the following language:
"A. Routine Discharge
A routine discharge occurs when a patient has completed treatment at this level of care and discharge criteria are met (ASAM Discharge Criteria). A routine discharge may result in continuing care at an intensive outpatient program (Level II), an outpatient program (Level I), or a longer term care environment, i.e. a halfway house."
Policy number 10.116 is titled, "ASAM Patient Placement Criteria" and included the following language:
"Policy: It is the policy of Marworth to utilize the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in all levels of the treatment program.
Procedure: 4. At the time of discharge, the Primary Counselor uses the ASAM "Discharge / Referral Criteria" (Attachment 3 of 3) as the patient is considered eligible for discharge to a different level of care. The counselor presents these criteria at Multidisciplinary Team Meeting."
As written, the policies failed to provide specific requirements for completion of treatment from the client ' s perspective.
The findings were reviewed with the Project Director during the P&P review.
|
Plan of Correction
Criteria for completion of treatment for Inpatient non-hospital level of care was developed on July 6, 2012 by a multi-disciplinary team comprising the Outpatient Coordinator, Director of Counseling and Medical Director and will come before a special meeting of the Leadership committee of Marworth for review and approval on or before July 13, 2012. Once approved, the Criteria will become part of the Written Plan and will be posted on the patient bulletin board. |
709.91(a)(3) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(3) Requirements for completion of treatment.
|
Observations
Based upon a review of the facility ' s Policy & Procedure (P&P) Manual, the facility failed to develop a written plan providing for intake and admission, which included requirements for completion of treatment from the client's perspective.
The findings include:
The P&P Manual was reviewed during the on-site inspection that was conducted from June 4-8, 2012.
Policy number 10.154 is titled, "Discharge Categories" and included the following language:
"A. Routine Discharge
A routine discharge occurs when a patient has completed treatment at this level of care and discharge criteria are met (ASAM Discharge Criteria). A routine discharge may result in continuing care at an intensive outpatient program (Level II), an outpatient program (Level I), or a longer term care environment, i.e. a halfway house."
Policy number 10.116 is titled, "ASAM Patient Placement Criteria" and included the following language:
"Policy: It is the policy of Marworth to utilize the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in all levels of the treatment program.
Procedure: 4. At the time of discharge, the Primary Counselor uses the ASAM " Discharge / Referral Criteria " (Attachment 3 of 3) as the patient is considered eligible for discharge to a different level of care. The counselor presents these criteria at Multidisciplinary Team Meeting."
As written, the policies failed to provide specific requirements for completion of treatment from the client's perspective.
The findings were reviewed with the Project Director during the P&P review.
|
Plan of Correction
Criteria for completion of treatment for Outpatient level of care was developed on July 6, 2012 by a multi-disciplinary team comprising the Outpatient Coordinator, Director of Counseling and Medical Director and will come before a special meeting of the Leadership committee of Marworth for review and approval on or before July 13, 2012. Once approved, the Criteria will become part of the Written Plan and will be posted on the patient bulletin board. |