INITIAL COMMENTS
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Graff, Tina
This report is a result of an on-site licensure renewal inspection conducted on June 6-8, 2016 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:
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Plan of Correction
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of two administrative discharges on June 7-8, 2016, the facility failed to notify one client of their involuntary discharge.
Client #1 was admitted to the facility on November 5, 2015 and was involuntary discharged on November 9, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will be re-educated on the notification form for involuntary discharges and the form will be completed on every involuntary discharge even if the patient refuses to sign. Training will be completed by 6/30/2016 by the Director of Counseling Programs and Counseling Managers. 100% of the involuntary discharges will be audited for 6 months to confirm compliance by the Director of Counseling Programs and Counseling Managers. |
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 a converstation with the Facility Director and the Director of Quality Assurance on June 6, 2016, the facility failed to document unusual incidents when it came to requirng the presence of ambulance personnel on site. Therefore, no unusual incidents reports were reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Marworth will file a written Unusal Incident Report for an event requiring the presence of police, fire or ambulance personnel and keep these on file in the facility for inspection. The staff responsible for filing these reports will be The Director of Counseling, Program Coordinator, Director of Nursing and the Medical Director. Forms have been distributed to all these departments for filing. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of partial hospitalization client records on June 8, 2016, the facility failed to document a preliminary treatment and rehabilitation plan during intake in six of six records reviewed.
Client #11 was admitted to treatment on January 28, 2016 and discharged on February 2, 2016.
Client #12 was admitted to treatment on March 3, 2016 and discharged on March 23, 2016.
Client #13 was admitted to treatment on February 25, 2016 and was discharged on March 2, 2016.
Client #14 was admitted to treatment on December 29, 2015 and discharged on January 14, 2016.
Client #15 was admitted to treatment on May 26, 2016 and was an active client at the time of the inspection.
Client #16 was admitted to treatment on May 31, 2016 and was an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon referral and at initial meeting with patient, a preliminary treatment plan will be developed by the counselor which will address the patient's needs at that particular time. Once the counseling assessment is completed additional areas will be added. Program Coordinator will re-educate staff about this by 6/30/2016 and to ensure compliance will review 5 charts a month for 6 months. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of six outpatient client records on June 8, 2016, the facility failed to document consent to treatment during the intake process in four of six outpatient records reviewed.
Client #11 was admitted to treatment on January 25, 2016 and discharged on February 2, 2016.
Client #12 was admitted to treatment on February 22, 2016 and discharged on March 23, 2016.
Client #17 was admitted to treatment on July 15, 2015 and discharged on November 24, 2015.
Client #20 was admitted to treatment on September 2, 2016 and is still an active client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Primary counselors will be re-educated on the need to have the Consent to Treat on every patient. Client #20 will receive a Consent to treat. The Program Coordinator will do the training by 6/30/2016 and will audit 5 records a month for 6 months to verify compliance. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records on June 8, 2016, the facility failed to document a preliminary treatment and rehabilitation plan during the intake process in six of six records reviewed.
Client #11 was admitted to treatment on January 25, 2016 and discharged on January 28, 2016.
Client #12 was admitted to treatment on February 22, 2016 and discharged on March 3, 2016.
Client #17 was admitted to treatment on July 15, 2015 and discharged on November 24, 2015.
Client #18 was admitted to treatment on December 10, 2015 and discharged on April 15, 2016.
Client #19 was admitted to treatment on April 25, 2016 and is still an active client.
Client #20 was admitted to treatment on September 2, 2016 and is still an active client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon referral and at initial meeting with patient, a preliminary treatment plan will be developed by the counselor which will address the patient's needs at that particular time. Once the counseling assessment is completed additional areas will be added. Program Coordinator will re-educate staff about this by 6/30/2016 and to ensure compliance will review 5 charts a month for 6 months. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of outpatient client records, the facility failed to document that the individual treatment and rehabilitation plan was developed with the client in three of six records reviewed.
Client #18 was admitted to treatment on December 10, 2015. The individual treatment and rehabilitation plan was developed on December 15, 2015 and was not signed by the client until March 17, 2016.
Client #19 was admitted to treatment on April 25, 2016. The individual treatment and rehabilitation plan was developed on May 17, 2016 and was not signed by the client at the time of inspection.
Client #20 was admitted to treatment on September 2, 2016 and is still an active client. The individual treatment and rehabilitation plan was developed on October 2, 2015 and was not signed by the client until October 13, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The counselors will be re-educated that the treatment plan needs to be developed and signed on the same day. The training will be done by the Program Coordinator by 6/30/2016 and will audit 5 charts a month for 6 months to assure compliance. |