INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Buprenorphine monitoring conducted on June 3, 2019 through June 5, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Malvern Institute 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that a staff person, who was hired into the counselor position, met the appropriate educational requirements prior to being hired. Employee #12 was hired as a counselor on April 23, 2019. The documentation provided indicated that the employee had a Bachelor of Science degree in Chemistry; however, Chemistry is not a qualifying degree.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Employee #12 has completed her Master of Arts in Counseling degree in May 2019. An official transcript has been requested and will be placed in her HR folder once it is received.
The HR manager at this site will monitor and review all qualification requirements for the position of a counselor. The HR team will periodically audit employee charts for completion and compliance. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation that the individual training plan, for the current training year, was developed with input from both the employee and the supervisor in 1 of 14 personnel records reviewed.
Employee # 2 was hired as the facility director on March 6, 2017. The individual training plan signed by the employee on January 25, 2019 was not signed by the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: The training plan developed by the supervisor and Employee #2 was signed by the supervisor.
The HR manager will follow up with all employees and their supervisors annually for completion of the training plan as well as signatures from both parties. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document the completion of 25 clock hours of annual training required for counselors for the facility's January 1, 2018 through December 31, 2018 training year in 1 of 14 employee files reviewed.
Employee #11's training file only documented 22 hours of required annual training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Employee's supervisor will present corrective action to Employee #11. The HR team will monitor all employee files to ensure requirements for training hours are met. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to develop, and make available to the public, their 2018 annual report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An annual report which includes the names of the members of the board will be made available to the public. The divisional director of business development will publish the completion and availability of the annual report in a public forum such as a public newspaper. A copy of the publishing will be kept on file for review. The Compliance Manager will review a copy of this document annually to ensure adherence to the regulation. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Corporate Risk Manager and the Compliance Manager will assemble a team that reviews Malvern's policies and procedures annually. The team will then present this to the Project Director to sign off annually upon completion. The Corporate Risk Manager and Compliance Manager will monitor policy reviews and will ensure its completion between November 1st and December 31 annually. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that the personnel records contained documentation of an annual written individual performance evaluation in two of eight applicable employee records reviewed.
Employee # 1 was hired as the project director on June 27, 2017. There was no documentation of an annual written individual performance evaluation completed for the review year.
Employee # 2 was hired as the facility director on March 6, 2017. There was no documentation of an annual written individual performance evaluation completed for the review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employees #1 and #2 had their written individual performance evaluation completed. The HR team will continue to manage employee files and ensure that all employees receive an annual performance evaluation. The HR manager will perform annual audits and send out reminders to deficient staff members to ensure compliance with the regulation. |
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
The facility failed to provide documentation that client #12 was notified, in writing, of the facility's decision to involuntarily terminate the client from treatment. Client #12 was admitted to the inpatient nonhospital level of care on April 2, 2019 and was invountarily discharged on April 17, 2019.
The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
Malvern Institute has a process in place that notifies the client of the reasons for an involuntary discharge and a process to appeal the decision. All clinicians will be trained by the clinical supervisor by July, 15th 2019 to use this documentation for all clients that are involuntarily discharged. The Performance Enhancement Coordinator will perform monthly chart audits to assess compliance. The Compliance Manager will discuss the progress with the clinical team. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual's identity, which is to include the name, address and date of birth, prior to the administration of a narcotic agent in 1 of 12 applicable client records reviewed.
Client # 5 was admitted on April 30, 2019 to the detox level of care and was discharged on May 5, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Malvern institute will verify the identity of each client prior to the administration of a narcotic agent. When identification is not readily available Malvern Institute will follow the guidelines laid out in licensing alert 01-2018 to verify the client's identity. The Director of Admissions and Utilization Management will train admissions staff on these guidelines and will conduct periodic chart checks to ensure compliance. Progress will be discussed at the monthly performance enhancement meetings. |