INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection monitoring conducted on May 30, 2024 through May 31, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection Malvern Treatment Centers 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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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent form in one of fourteen client records reviewed. Client #13 was admitted to the detoxification level of care on August 28, 2023 and was discharged on September 3, 2023. A release of information form was signed and dated by the client on August 29, 2023; however, the consent form did not include the name of the person, agency, or organization to whom the disclosure was to be made to. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The release of information failed to document the name of the person, agency or organization to whom disclosure is made. The release of information was signed and dated by the client, but the release did not identify a person, agency or organization to whom the information was to be released.
Action: Clinicians have been re-educated on identifying a person, agency or organization on all releases.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding client signatures for all releases prior to discharge. 25 charts will be audited each month with a goal of 100% compliance for 3 months.
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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 client records, the facility failed to document the specific information to be disclosed on release of information forms in four of fourteen client records reviewed.Client #3 was admitted to the residential level of care on April 20, 2024 and was still active at the time of inspection. The release of information form to an emergency contact was signed and dated by the client on April 20, 2024, but the release form indicated the "entire record" was to be released, which was not specific to the purpose of the disclosure. Client #5 was admitted to the residential level of care on January 18, 2024 and was discharged on February 14, 2024. The release of information form to an external treatment provider was signed and dated by the client on January 23, 2024, but the release form indicated the "entire record" was to be released, which was not specific to the purpose of the disclosure. Client #6 was admitted to the residential level of care on September 9, 2023 and was discharged on October 24, 2023. The release of information form to an external treatment provider was signed and dated by the client on September 9, 2023, but the release form indicated the "entire record" was to be released, which was not specific to the purpose of the disclosure. Client #13 was admitted to the detoxification level of care on August 28, 2023 and was discharged on September 3, 2023. A release of information form to an emergency contact was signed and dated by the client on August 30, 2023 and a release of information form to a primary care physician was signed and dated by the client on August 28, 2023, however, both release forms indicated the "entire record" was to be released, which was not specific to the purpose of the each disclosure.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: Staff were operating with the assumption that they could use the "entire record" check box on the release of information forms.
Action: The release of information for Client #3 was removed from the chart and a new release was completed, dated, and signed by the patient. The release in Client #3's chart now specifies the items to be released. Staff were educated in assisting the patient in selecting each item to be released individually. The release of Information document in the EMR was modified to remove the 'entire record' checkbox. The 'entire record' option will no longer be an option to select when completing a release of information.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with selecting each item identified by the patient for release on the release of information forms in the EMR. 25 charts will be audited each month with a goal of 100% compliance for 3 months.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of fourteen client records reviewed. Client #6 was admitted to the residential level of care on September 9, 2023 and was discharged on October 24, 2023. The release of information form to another treatment provider was signed and dated by a witness on October 24, 2023, but the dated signature of the client was not included on the release form. Client #9 was admitted to detoxification level of care on May 26, 2024 and was still active as of the date of inspection. The release of information form to the funding source was signed and dated by a witness on May 26, 2024, but the dated signature of the client was not included on the form. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: Client #6 and Client #9 records contained a release of information that failed to document the client's signature and date on the release of information. The release of information was signed and dated by a witness, but was not signed and dated by the client
Action: Client #9 has discharged from treatment. The Clinical Director provided one on one re-education with the staff member who initiated the release of information. In addition, all staff have been re-educated in obtaining client signatures and dates on all releases.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding client signatures for all releases prior to discharge. 25 charts will be audited each month with a goal of 100% compliance for 3 months.
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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 the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of two applicable client records reviewed.Client #13 was admitted to the detoxification level of care on August 28, 2023 and was involuntarily discharged on September 3, 2023. There was no documentation in the record that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The Clinician/Clinical Supervisor failed to notify the client, in writing, of the facility's decision and reason to involuntary termination the client's treatment.
Action: The clinical staff have been re-educated on the completion of written notification, which is to include the reason for the facility's decision to involuntarily terminate the client's treatment.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding the written documentation of the client being notified of the facility's decision and reasoning to terminate treatment. 100% of involuntary terminations will be audited with a compliance rate of 100% for 6 months.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of two applicable client records reviewed.Client #13 was admitted to the detoxification level of care on August 28, 2023 and was discharged on September 3, 2023. There was no documentation in the record that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Malvern Treatment Centers' Discharge Planning Policy states that staff is to notify the client of their rights of involuntary termination and allow the client the right to request reconsideration of the facility's decision to terminate treatment. The facility failed to provide the client with the opportunity for reconsideration.
Action: Clinical staff was re-educated on the Discharge Planning Policy regarding the client's rights to appeal the facility's decision for termination and clinical documentation of the client having been made aware of their right to appeal. Staff was re-educated on the process of completing this documentation prior to discharge.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding the documentation of clients having the opportunity to request reconsideration of the facility's decision to terminate treatment. 100% of involuntary terminations will be audited with a compliance rate of 100% for 6 months.
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