INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, 2023 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of one applicable client records reviewed. The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.Client # 12 was admitted to the inpatient non-hospital activity on March 19, 2023 and was discharged against medical advice on April 1, 2023; however, the emergency contact was not notified until April 3, 2023.This is a repeat citation from the June 2, 2022 annual licensing inspection.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 document the contacting of the client's emergency contact within 12 hours of the client leaving treatment against medical advice.
Action: All clinicians were re-educated that the emergency contact must be notified within 12 hours of a client leaving treatment against medical advice, and that the notification must be documented in the client's chart.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance with documenting contact with the emergency contact within 12 hours of a client leaving the facility against medical advice as outlines in standard 709.24 (a) (3). 15 charts will be audited each month with a goal of 100% compliance for 6 months. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's July 2022 through May 2023 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.There were incidents at the facility that required the presence of police and/or ambulance personnel at the facility on September 4, 2022 and September 22, 2022; however, both incidents were not reported to the Department until October 6, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The Department failed to receive unusual incident reports within 3 business days following the event days.
Action: The Risk Manager was re-educated on the standard of reporting unusual incidents and submission process within 3 business days following an unusual event. The Risk Manager will file all unusual incident reports with the Department within 3 business days of the unusual event.
Monitoring: The submission of unusual incident reports will be completed with 100% compliance as outlined in standard § 709.34 (c) (4); reporting of unusual incidents. |