INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 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 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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704.11(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
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2022 through December 31, 2022 training year in one of two applicable personnel records reviewed.Employee # 15 was hired as a counselor on June 16, 2018. The personnel record documented 23.5 hours of training received during the training year reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The individual counselor thought she had met her annual 25 clock hours of training but when she was required to submit the certificates at the end of the year, she realized she was short 1.5 hours.
Action: The clinical teams were re-educated on the requirement to complete the required training hours based on their position.
Monitoring: The Clinical Director and Human Resource Manager will send quarterly reminders regarding completing required trainings. All clinical staff will be required to submit verification of training by November 30th to identify those not in compliance and communicate the remaining needs to the deficient clinical staff. |
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 # 11 was admitted to the inpatient non-hospital activity on October 10, 2022 and was discharged against medical advice on October 24, 2022. There was no documentation of follow-up to the emergency contact within 12 hours, in the record, at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Client 11 had multiple emergency contacts (EC) listed and one of the ECs was contacted and came to pick up the client but it was not clearly documented which EC was contacted.
Action: Staff were re-educated on policy PC 118 AMA - AWOL-Missing Person to contact and document that the EC was contacted within 12 hours when a client leaves AMA or AWOL.
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 regarding the counselor documenting that the EC was contacted within 12 hours after an AMA or AWOL discharge. In the case of multiple ECs, the counselor will document which EC was contacted. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a discharge summary, in two of four applicable records reviewed.Client # 11 was admitted into the Inpatient Non-Hospital Residential activity on October 10, 2022 and discharged on October 24, 2022. The record did not include a discharge summary at the time of the inspection.Client # 12 was admitted into the Inpatient Non-Hospital Residential activity on November 4, 2022 and discharged on November 20, 2022. The record did not include a discharge summary at the time of the inspection.This is a repeat citation from the June 24, 2022 annual licensing inspection.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The counselors failed to complete the discharge summary per facility policy.
Action: The clinical staff were re-educated on the 709.53 (a)(10) requirement to complete the discharge summary and were re-educated on policy PC 135 - Discharge Planning and sign acknowledgement and understanding of the policy. Additionally, a weekly clinical team meeting has been initiated and upcoming discharges are discussed during the meeting to assure all requirements are met. A leadership board was developed in the EMR which can identify discharged patients requiring discharge summaries. The clinical team will review the leadership board daily to assure the timely completion of discharge summaries.
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 completing the discharge summary. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |