INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13-15, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate treatment at the project in one of one client records.
The findings include:
One client record requiring documentation of written notification of involuntary termination was reviewed on November 15, 2013. The facility failed to document that the client was provided written notification of involuntary termination in client record # 14.
Client # 14 was admitted on June 26, 2013 and was involuntarily discharged on August 8, 2013. As of November 15, 2013, the facility failed to document in the record that client # 14 was provided written notification of involuntary termination at the project.
The Clinical Supervisor confirmed the findings.
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Plan of Correction
Counselors were unaware of the requirement to complete the Therapuetic Discharge Form in the Electronic Medical Record System for any patient involuntarily discharged. This form includes the notification to the patient of the patient's right to appeal.
Counselors will be educated on the requirement and use of the Therapuetic Discharge Form. This education will be documented.
The Clinical Supervisor will conduct monthly medical record reviews to ensure completion of the Therapuetic Discharge form for all involuntary discharges. |
709.63(a) LICENSURE Client record
709.63. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record, which included follow-up information, in one of one client records.
The findings include:
One client record requiring documentation of follow-up information was reviewed on November 15, 2013. The facility failed to document follow-up information in client record # 14.
Client # 14 was admitted to the program on 6/26/13 and was therapeutically discharged on 8/5/13. The facility failed to document follow-up information in client record # 14 as of 11/15/13.
The Facility Director confirmed the findings.
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Plan of Correction
The Utilization Managment department at Willow Grove will be trained in the procedure for conducting patient follow-up. This training will be documented.
The Utilization Management department will begin conducting patient follow-up on 12/9/13 and will document this follow-up in the "Patient Follow-up Excel Spreadsheet".
The Clinical Supervisor will conduct monthly medical record reviews to ensure follow-up is being completed as required. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in two of two client records reviewed.
The findings include:
Two client records requiring documentation of an aftercare plan, a discharge summary, and/or follow-up information were reviewed on November 15, 2013. The facility failed to document a complete client record for clients # 8 and 13.
Client # 8 was admitted on June, 27, 2013 and discharged on July 5, 2013. The facility failed to document follow-up information in client record # 8, as of November 15, 2013. The facility failed to document an aftercare plan that included a contact person and the reentry process. Additionally, the discharge summary was late as it was documented on August 19, 2013.
Client # 13 was admitted on July 18, 2013 and discharged on August 19, 2013. The facility failed to document follow-up information in client record # 13, as of November 15, 2013. Additionally, the discharge summary was late as it was documented on November 1, 2013.
The Facility Director confirmed the findings.
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Plan of Correction
The Utilization Management Department at Willow Grove will be trained in the procedure for conducting patient follow-up. This training will be documented. The Utilization Management department will begin conducting patient follow-up on 12/9/13 and will document this follow-up in the "Patient Follow-up Excel Spreadsheet". The Clinical Supervisor will conduct monthly medical record reviews to ensure follow-up is being completed as required.
Counselors will be re-educated on the requirtments for completion of aftercare plans. This education will address the requirements for documenting the contact person and reentry process on the aftercare plan. This education witht he counselors will be documented.
Counselors will be re-educated on the requiements for completiong of discharge summaries within 7 days. This education will be documented.
The clinical Supervisor will conduct monthly medical record reviews to ensure completion of aftercare plans and the timely completion of discharge summaries. |