INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 9-10, 2021 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of seven client records, the facility failed to document a client orientation to the project which shall include, but is not limited to, a familiarization of project policies in all records reviewed.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Facility Director updated Client Orientation to reflect our telemedicine model to include project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation.
Current orientation packet was reviewed and revised to reflect telemedicine model.
i. Our orientation packet was revised to include, project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation
ii. Approval for revised orientation packet will be complete on 6/25/2021 by Facility Director and Counseling Director
a. Facility Director and Counseling Director to supply education to Office Coordinator /designee and outpatient counselors/designee
b. Client orientation will be supplied to all of the above designees electronically to be distributed to all active clients and all new clients beginning 7/1/2021. Documentation of distribution will be placed in medical record.
a.Counseling Director to perform audits.
b.Review 30 active client charts to ensure orientation has been distributed and documented in medical record.
c.Audit will begin on 7/26/2021 and will continue until 3 consecutive months of 100% compliance are achieved.
i. Results will be compiled and distributed at our PI meeting 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.
|
Observations
Based on a review of seven client records, the facility failed to document a client orientation to the project which shall include, but is not limited to, a familiarization of hours of operation in all records reviewed.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Facility Director updated Client Orientation to reflect our telemedicine model to include project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation.
Current orientation packet was reviewed and revised to reflect telemedicine model.
i. Our orientation packet was revised to include, project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation
ii. Approval for revised orientation packet will be complete on 6/25/2021 by Facility Director and Counseling Director
a. Facility Director and Counseling Director to supply education to Office Coordinator /designee and outpatient counselors/designee
b. Client orientation will be supplied to all of the above designees electronically to be distributed to all active clients and all new clients beginning 7/1/2021. Documentation of distribution will be placed in medical record.
a. Counseling Director to perform audits.
b. Review 30 active client charts to ensure orientation has been distributed and documented in medical record.
c. Audit will begin on 7/26/2021 and will continue until 3 consecutive months of 100% compliance are achieved.
i. Results will be compiled and distributed at our PI meeting 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)(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.
|
Observations
Based on a review of seven client records, the facility failed to document a client orientation to the project which shall include, but is not limited to, a familiarization of the fee schedule in all records reviewed.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Facility Director updated Client Orientation to reflect our telemedicine model to include project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation.
Current orientation packet was reviewed and revised to reflect telemedicine model.
i. Our orientation packet was revised to include, project policies, services provided, changes in scheduling, electronic release procedure, fee schedule & hours of operation
ii. Approval for revised orientation packet will be complete on 6/25/2021 by Facility Director and Counseling Director
a. Facility Director and Counseling Director to supply education to Office Coordinator /designee and outpatient counselors/designee
b. Client orientation will be supplied to all of the above designees electronically to be distributed to all active clients and all new clients beginning 7/1/2021. Documentation of distribution will be placed in medical record.
a. Counseling Director to perform audits.
b. Review 30 active client charts to ensure orientation has been distributed and documented in medical record.
c. Audit will begin on 7/26/2021 and will continue until 3 consecutive months of 100% compliance are achieved.
i. Results will be compiled and distributed at our PI meeting 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
|