INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13-17, 2009 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 and a plan of correction is due on August 15, 2009.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of staff development records, the facility failed to provide a mechanism to collect feedback from employees on training completed from outside sources.
Findings:
On July 16, 2009 staff development records were reviewed. There was no documentation of employee feedback on trainings completed outside the facility.
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Plan of Correction
Marworth was unaware of standard requiring employee feedback on outside training. Staff development coordinator has been educated on this requirement and will ensure compliance for all employees who receive outside training. These results will be reported monthly by staff development coordinator at the monthly meeting. |
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 the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days.
Findings:
On July 13,14 & 15, 2009, 19 client records were reviewed. Seven were outpatient client records. Of those seven, four required treatment plan updates. One of four records reviewed lacked treatment plan updates. Client #13 ' s comprehensive treatment plan was completed on 11/12/08. Treatment plan updates were due on January 12, 2009, March 12, 2009, and May 12, 2009. There were no treatment plan updates until 7/2/09.
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Plan of Correction
The Outpatient Counseling Coordinator and counseling staff are knowledgible and aware of the timeline requirements for treatment plan updates. Human error contributed to the lack of an update in the one record. The IT Coordinator for Marworth has designed and implemented a documentation alert into the electronic medical record notifying counseling staff on treatment plan review due dates. The alert system will eliminate human error. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document that case consultations had been performed at least quarterly. Facility policy for outpatient services stated that case consultations are performed at the same time as treatment plan reviews which is every 60 days (policy states that case consultations may be also performed at any time or when necessary).
Findings:
The facility completes their case consultations concurrently with the treatment plan updates and refers to them as the Master Treatment Plan (MTP). On July 13,14 & 15, 2009, 19 client records were reviewed. Seven were outpatient client records. Of those seven, four required case consultation notes. One of four records reviewed lacked case consultation notes within required time frames Facility policy states that case consultations are due every 60 days. Client #13's record did not contain case consultation notes for a period exceeding 6 months. Client #13's initial comprehensive treatment plan was completed on 11/12/08. Case consultation notes were due on January 12, 2009, March 12, 2009, and May 12, 2009. There were no case consultation notes in record #13 until July 2, 2009.
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Plan of Correction
The Outpatient Conseling Coordinator and counseling staff are knowledgible and aware of the timeline requirements for case consultation notes. The IT coordinator for Marworth has designed and implemented a documentation alert, for case consultations,into the electronic medical record notifying counseling staff on case consultation review due dates. The alert system will eliminate human error. |