INITIAL COMMENTS
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This report is a result of an off-site investigation conducted on January 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site investigation, 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 investigation and a plan of correction is due on February 14, 2010.
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the facility tour, the facility failed to ensure that all heaters that were permanently mounted or installed.
The findings include:
Based on observation the facility failed to ensure that all heaters were permanently mounted or installed. During the onsite visit the drug and alcohol specialists observed a space heater on the floor in the facility director's office. The facility director confirmed that they were aware of the standard and the requirement to have all heaters mounted or installed and explained that this was the only source of heat in this office.
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Plan of Correction
A heater is to be installed and permanently mounted in office where space heater was found on Tuesday February 9. To be monitored by project director. |
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 the review of the facility policy and client records, the facility failed to follow written procedures for the management of treatment/ rehabilitation services for clients.
The findings include:
Based on the review client records on January 20, 2010 and a review of the facility policy regarding incident reports that specified that an "incident will be reported using (an) Incident Report Form to ensure the safety of employees, patients, and visitors", the facility failed to follow their procedure for reporting incidents to the PA Department of Health. The policy stated: "All incident reports shall be forwarded to the Pennsylvania Department of Health." Additionally, the facility policy specified incident reports would be written to include assaultive behavior and illicit substance use.
Client records # 3 and # 4 documented allegations of physical assault by one patient towards another patient. In client record # 3 documentation pertaining to an alleged assault of this patient was addressed. Client record # 4 provided documentation that specified client # 4 had allegedly assaulted another client. Additional documentation in client record # 4 specified client # 4 admitted to drug use while in treatment. The facility failed to submit incident reports to the Department of Health in reference to these incidents.
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Plan of Correction
Incident report forwarded to DOH. In future, Project Director will ensure and monitor all incident reports are forwarded to DOH immediately following incident. |