INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 7-8, 2024 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:
|
Plan of Correction
|
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling room. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director will submit plan to request a waiver as directed by June 1, 2024. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each patient's bathroom. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Manager of hospitality services and supervisor of general maintenance will place individual paper towels in each individual bathroom by June 1, 2024. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill logs from July, 2023 through April, 2024 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on July 15, 2023 and then not again until April 19, 2024.This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Security will conduct fire drill during sleep hours every six months. Supervisor of security will complete performance indicator (PI) audit every six months and present to PI group for compliance. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisor of general maintenance will post hours of operation on outpatient facility main door to be visible to general public by June 1, 2024. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisor of general maintenance will post emergency telephone number on outpatient facility main door to be visible to general public by June 1, 2024. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
Based on a review of inpatient client records, the facility failed to document proposed type of support service on individual treatment plans in five out of six records reviewed.Client #9 was admitted on April 15, 2024 and was still active at the time of the inspection. The treatment plan was dated April 19, 2024.Client #10 was admitted on April 4, 2024 and was still active at the time of the inspection. The treatment plan was dated April 4, 2024.Client #11 was admitted on March 4, 2024 and was still active at the time of the inspection. The treatment plan was dated March 4, 2024. Client #13 was admitted on April 10, 2024 and was still active at the time of the inspection. The treatment plan was dated April 12, 2024. Client #14 was admitted on April 5, 2024 and was still active at the time of the inspection. The treatment plan was dated April 5, 2024. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical Director will work with IT department to add in section on treatment plan to include support services by June 1, 2024. Clinical Director will review with inpatient team that support services needs to be outlined in each individual treatment plan under Dimension 6. Clinical Director will conduct monthly audits of 10 active charts to determine compliance. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of inpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of one applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed seven days following discharge.Client #12 was admitted on April 25, 2024 and discharged on April 30, 2024. A follow up was due no later than May 6, 2023; however, none was competed. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Counseling secretary and/or alumni coordinator will place a follow-up phone call to each discharged patient and document in chart within 7 days of discharge. Clinical Director will complete monthly audit of 10 discharged patients (routine, AMA and TD) to maintain compliance. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.Client #2 was admitted on August 29, 2023 and was discharged on April 18, 2024. A comprehensive treatment plan was completed on August 30, 2023 and an update was due no later than October 30, 2023; however, it was not completed until November 14, 2023. Client #3 was admitted on August 14, 2023 and was discharged on March 26, 2024. A treatment plan update was completed on November 20, 2023 and an update was due no later than January 20, 2024; however, it was not completed until February 6, 2024.Client #4 was admitted on February 10, 2023 and was still active at the time of the inspection. A treatment plan update was completed on February 23, 2024 and the next update was due no later than April 24, 2024; however, none was completed.These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the June 2, 2022 and July 12, 2023 licensing inspections.
|
Plan of Correction
Clinical Director will work with outpatient team to develop tracker to monitor 60 day treatment plan updates. Tracker will include list of active patients, initial treatment plan due date and 60 day due date. Outpatient counselor will update treatment plan every 60 days. Clinical Director will complete monthly PI audit of 10 charts to maintain compliance and present PI data to team in monthly meeting. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of outpatient client records, the facility failed to document a discharge summary within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states that the discharge summaries must be completed seven days following discharge.Client #1 was admitted on December 6, 2023 and discharged on March 7, 2024. No discharge summary was completed. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Outpatient therapist will complete discharge summary within seven days of discharge. Clinical Director will complete PI audit once per month of 10 charts and present to PI team to maintain compliance. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisor of general maintenance will post hours of operation on outpatient facility main door to be visible to general public by June 1, 2024. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Supervisor of general maintenance will post emergency telephone number on outpatient facility main door to be visible to general public by June 1, 2024. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of outpatient client records, the facility failed to comply with plans of correction that were approved by the Department. Plan of corrections for treatment plan updates were submitted and approved by the Department for the July 12, 2023 and June 2, 2022 annual licensing inspections. Treatment plan updates was again found to be a deficiency in the May 8, 2024 licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director will work with outpatient team to develop tracker to monitor 60 day treatment plan updates. Tracker will include list of active patients, initial treatment plan due date and 60 day due date. Outpatient counselor will update treatment plan every 60 days. Clinical Director will complete monthly PI audit of 10 charts to maintain compliance and present PI data to team in monthly meeting.
Facility plans to review current plan of correction with support of compliance specialist. Clinical Director and Executive Director will monitor plans of correction on quarterly basis in order to ensure citation does not occur again.
By providing further training to team members who do not meet expectations, we are offering them an opportunity to improve. If compliance issues persist, the use of progressive discipline will be implemented to ensure accountability. Additionally, our goal of reviewing approximately 40% of charts over a year time frame demonstrates our commitment to monitoring and maintaining compliance. This systematic approach will help identify any potential issues and take necessary actions to rectify them. Lastly, setting a deadline for implementing the plan, which is June 1, 2024. Having a specific timeline ensures that the corrective measures are put into action in a timely manner. |