INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4 & 5, 2025 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:
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the facility's policy and procedures manual the project director failed to 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 an assessment of staff training needs, an overall plan for addressing these needs, a mechanism to collect feedback on completed training, and an annual evaluation of the overall training plan.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has reviewed the current staff development program and has updated the Competency Policy to include both responsible parties and timeframes for the assessment of staff training needs, the overall plan for addressing these needs, a mechanism to collect feedback on completed training, and an annual evaluation of the overall training plan. This plan will be implemented accordingly in the overall staff development program at Marworth. Clinical Director is responsible for monitoring compliance with plan of correction.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the May 2024 through April 2025 fire drill logs during the inspection, the facility failed to document the exit route used during the drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All facility fire drill logs from May 2024 through April 2025 have been updated to illustrate the exit route used. Pathways for evacuation have been defined and exit doors have been identified. This will continue to be illustrated in all fire drills moving forward. Security Manager is responsible for monitoring that this plan of correction is being done. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility ' s written plan for the coordination of client treatment and rehabilitation services which includes but is not limited to the written procedures for the management of treatment/rehabilitation services for clients, the facility failed to include procedures with time frames for the completion of the individual treatment and rehabilitation plan and follow up contacts.
Based on the review of client records, the facility also failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in three out of five applicable records reviewed.
Client #4 was admitted to the inpatient level of care on May 18, 2025, and left against medical advice on May 29, 2025. There was no documentation that the emergency contact was notified.
Client #12 was admitted to the detoxification level of care on May 30, 2025 and left against medical advice on May 31, 2025. There was no documentation that the emergency contact was notified.
Client #13 was admitted to the detoxification level of care on August 2, 2024 and left against medical advice on August 4, 2024. There was no documentation that the emergency contact was notified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update documentation policies and procedures to include the following timelines: (1) Treatment plans to be completed and signed by patient within 7 days of admission; (2) integrated summaries to be completed within four business days from initial session with patient and (3) discharge summaries to be completed within 7 calendar days of discharge. Medical Records staff will complete weekly audit of the above documentation and submit any deficiencies to clinical director and two counseling managers to ensure compliance. Counseling managers will meet with any counselors who have deficient documentation with expectation that all documentation will be finalized within 24 hours of notice. Counselors who identify a pattern of deficient documentation will be placed on a performance improvement plan (PIP). Clinical Director is responsible for monitoring compliance. In addition to above chart audits, training will be provided to counseling and specialist staff regarding AMA procedure to include contacting emergency contact upon discharge. A contact note will be placed in patient's chart to identify that emergency contact was notified. Counseling managers will complete monthly audit of AMA discharges to ensure compliance. Clinical Director responsible for monitoring compliance. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of twenty-one records reviewed.
Client #7 was admitted to the inpatient level of care on March 21, 2025 and discharged on April 15, 2025. The record contained two informed and voluntary consents to a drug and alcohol facility that were signed and dated by the client on March 26, 2025, that did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Medical records department completed an in-person release training for case managers, clinical staff, specialist staff and admissions department. Audits will be conducted once per month by counseling managers on ten random charts to review compliance and accuracy. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in three out of twenty-one records reviewed.
Client #3 was admitted to the detox level of care on May 10, 2025, stepped down to the inpatient level of care on May 13, 2025, and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a funding source dated and signed by the client on May 10, 2025, that did not identify the purpose for disclosure.
Client #7 was admitted to the inpatient level of care on March 21, 2025 and discharged on April 15, 2025. The record contained two informed and voluntary consents to release information to drug and alcohol facilities signed and dated by the client on March 26, 2025, that did not identify the purpose for the disclosure.
Client #13 was admitted to the detox level of care on August 2, 2024 and discharged on August 4, 2024. The record contained an informed and voluntary consent to release information to a family member/emergency contact signed by the client on August 2, 2024, that did not identify the purpose for the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical records department completed three in-person release trainings in May of 2025 for case managers, clinical staff, specialist staff and admissions department to highlight the importance of checking purpose of disclosure. New staff will receive individual training by their hiring supervisor during orientation period. Audits will be conducted once per month by counseling managers on ten random charts to review compliance and accuracy. Follow-up training will be provided by clinical director to any staff member who demonstrated errors in completion of releases during audit selection. Clinical Director is responsible for monitoring compliance. The current release was not updated due to patient being discharged. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation according to the facility ' s policy and procedures manual in four out of seven records reviewed. The facility policy and procedures manual states that the psychosocial evaluation is completed within four days of admission.
Client #1 was admitted on April 20, 2025 and was still active at the time of the inspection. A psychosocial evaluation was due no later than April 24, 2025; however, it was completed on May 19, 2025.
Client #4 was admitted on May 18, 2025 and discharged on May 29, 2025. A psychosocial was due no later than May 22, 2025; however, it was completed on May 26, 2025.
Client #5 was admitted on February 14, 2025 and discharged on March 11, 2025. A psychosocial evaluation was due no later than February 18, 2025; however, it was completed on February 26, 2025.
Client # 7 was admitted on March 21, 2025 and discharged on April 15, 2025. A psychosocial evaluation was due no later than March 25, 2025; however, it was completed on March 31, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director updated policy and procedure on Integrated Summaries (psychosocial evaluations) to include that completion of integrated summaries are due within four business days of counselor's initial session with patient. To ensure compliance, Medical Records staff will complete weekly audit of integrated summaries and submit any deficiencies to clinical director and two counseling managers. Counseling managers will meet with any counselors who have deficient documentation with expectation that all documentation will be finalized within 24 hours of notice. Counselors who identify a pattern of deficient documentation will be placed on a performance improvement plan (PIP).
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.
Client #4 was admitted on May 18, 2025 and discharged on May 29, 2025. The treatment plan dated May 18, 2025, indicated one individual session and four clinical groups a week. There was no documentation of the client receiving group therapy the weeks of May 18 and 25, 2025. In addition, there was no documentation that the client received individual therapy the week of May 18, 2025.
Client #5 was admitted on February 14, 2025 and discharged on March 11, 2025. The treatment plan dated February 14, 2025, indicated weekly one individual session and four clinical groups a week. There was no documentation that the client received an individual session the week March 2, 2025, and there is no documentation that any groups occurred.
Client #6 was admitted on December 11, 2024 and discharged on January 4, 2025. The treatment plan dated December 18, 2024, indicated one individual session and four clinical groups a week. There was no documentation that the client received individual therapy the week of December 29, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review with clinical team in monthly staff meeting the expectation of conducting and documenting one weekly individual session with each patient and completion of one group note that covers four small group therapy sessions conducted in a one-week period. Counseling managers will review charts of active patients under their supervisees on Friday afternoons to ensure compliance. In the event that a counseling manager is scheduled off, clinical director will conduct chart audit. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 the review of client records and the facility ' s policy and procedures manual, the facility failed to provide a complete client record which is to include a case consultation within the first week of admission and the third week of treatment, per facility policy, in three out of seven client records.
Client #4 was admitted on May 18, 2025 and discharged on May 29, 2025. There was no documentation that a case consultation occurred.
Client #5 was admitted on February 14, 2025 and discharged on March 11, 2025. There was no documentation that any case consultations occurred.
Client #6 was admitted on December 11, 2024 and was discharged on January 4, 2025. A case consultation occurred on December 16, 2024; however, there is no documentation that a second case consultation occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors participate in MTP meetings (case consultation) twice per week. Counselors present first week reviews and third week reviews on patients and document in chart under "MTP Note." Counseling manager facilitating MTP meeting will document cases presented and check patient chart at end of day to make sure documentation was placed in chart. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility ' s policy and procedures manual, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary within seven days, per facility policy, in two of four applicable records.
Client #5 was admitted February 14, 2025 and discharged on March 11, 2025. A discharge summary was due no later than March 18, 2025; however, it was completed on March 28, 2025.
Client #6 was admitted on December 11, 2024 and was discharged on January 4, 2025. A discharge summary was due no later than January 11, 2025; however, it was completed on January 20, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will update the discharge summary policy and procedure to include that discharge summaries are due within seven calendar days of patient discharge. Medical Records staff will complete weekly audit of the above documentation and submit any deficiencies to clinical director and two counseling managers to ensure compliance. Counseling managers will meet with any counselors who have deficient documentation with expectation that all documentation will be finalized within 24 hours of notice. Counselors who identify a pattern of deficient documentation will be placed on a performance improvement plan (PIP). |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in four out of four applicable records reviewed.
Client #15 was admitted on September 17, 2024 and discharged on February 28, 2025.The record did not include documentation that a follow up occurred.
Client #16 was admitted on August 13, 2024 and discharged on January 23, 2025. The record did not include documentation that a follow up occurred.
Client #17 was admitted on October 29, 2024 and discharged on February 25, 2025. The record did not include documentation that a follow up occurred.
Client #18 was admitted on November 8, 2024 and discharged on February 28, 2025. The record did not include documentation that a follow up occurred.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Outpatient secretary will conduct follow-up calls to discharged patients within seven days of discharge. Outpatient secretary will place a contact note in chart documenting the encounter. Outpatient Director will conduct monthly audit to monitor compliance. |