INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9-11, 2018, by staff from the Division of Drug and Alcohol Program Licensure. 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)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that all of its staff had the required training in communicable diseases. A total of 17 personnel files were reviewed for the on-site inspection.
Staff Person #10 was hired on October 5, 2015, to do art therapy, and was required to complete 6 hours of HIV/AIDS and 4 hours of TB/STD by October 5, 2017, but the staff person did not complete the the 6 hours of HIV/AIDS training until March 14, 2018, and the 4 hours of TB/STD training until March 28, 2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The department Directors/Managers will be re-educated regarding the required training in communicable diseases and the time frame of completion. This re-education will be completed at the Leadership meeting on August 22, 2018 by the Vice President. A training review will be completed on all new hires to ensure that the required training has been completed within the required time frame. This review will be completed for the next 4 months. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The file room in the outpatient office was unlocked and propped open during the physical plant inspection conducted on July 10, 2018. Client names, client numbers and client billing information was accessible to anyone entering the room.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The file room has been locked and the staff have been educated regarding the need to secure the door at all times by the Outpatient Program Director on July 16, 2018. Rounds will be conducted randomly to ensure that the file room door in the outpatient office remains locked. These rounds will occur for the next 4 months. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to ensure that it obtained written acknowledgement from clients that it notified clients of their rights. A total of 27 client records were reviewed during the on-site inspection including records for the inpatient non-hospital rehabilitation activity, inpatient non-hospital short-term detoxification activity, partial hospital activity and outpatient activity.
The 7 records reviewed for inpatient non-hospital rehabilitation activity, and the 7 records reviewed for the inpatient non-hospital short-term detoxification activity, did not document that the clients were notified that the project could not discriminate against them based on age, sex, ethnicity, color, marital status or handicap.
These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
The electronic medical record will be updated for inpatient non-hospital rehabilitation activity and for the inpatient non-hospital short-term detoxification activity to include age, sex, ethnicity, color, marital status or handicap. This change was completed by August 31, 2018. The department Director/Manager has educated the staff regarding the electronic medical record update at the departmental staff meeting on September 3, 2018. On September 10, 2018, a medical record review will be completed to ensure that all of the client rights are noted in the electronic medical record for the inpatient non-hospital rehabilitation activity and for the inpatient non-hospital short-term detoxification activity. |