Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 11, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Malvern Institute for Psychiatric and Alcoholic Studies, Inc. 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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Observations
Based on the review of the Staffing Facility Requirements Summary Report and personnel records, the facility failed to ensure that employee #6 received the minimum of six hours of HIV/AIDS training and four hours of TB/STD training within the regulatory timeframe.
Employee # 1 was hired as a counselor on May 1, 2019 and was due to have HIV/AIDS and TB/STD training no later than May 1, 2020; however, there was no documentation of the completion of the HIV/AIDS training or the TB/STD training on file.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure
Employee # 1 hired on May 1, 2019 was scheduled to attend HIV/AIDS/TB/STD training on March 25. Due to the COVID-19 pandemic all facility and contracted training were cancelled for the months of March-June. This documentation was provided during the survey.
Action
The Director of HR and the Director of Quality reviewed and approved Malvern Institutes training policy 8000.065.
Employee #1 is scheduled for the next available training in the month of July.
Monitoring
Upon hire all staff members are assigned mandatory training with a timeframe for completion based on their job description. The Human Resources Department maintains a tracking grid to ensure training are scheduled and completed within the required timeframe.
The HR department will send training requirement reminders to each staff member and their supervisor prior to required deadlines.
Malvern Institute will identify a staff member to be trained in the DDAP core curriculum of HIV/AIDS/STD/TB in the case the facility is unable to obtain a contracted trainer to meet the facility needs.
Compliance rates with staff training requirements will be reported to the Director of HR monthly to ensure compliance. Monthly reporting of staff training compliance will continue until Malvern Institute has reached 100% compliance for 4 months. June 1, 2020
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