INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted May 13, 2025 through May 14, 2025, 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:
|
Plan of Correction
|
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.
|
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 is made on a consent to release information form in one of fourteen client records reviewed.
Client # 2 was admitted to the inpatient non-hospital detoxification activity on May 10, 2025 and was active at the time of inspection. The release of information form to a family member/friend was signed by the client on May 10, 2025; however, the name of the person, agency, or organization to whom the disclosure would be made to was not included on the release form.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Identification of Failure: The Family Member/Friend ROI for Client # 2 admitted May 10, 2025 did not include the name of the person, agency, or organization to whom the disclosure would be made. The patient declined to designate an EC and the employee completing the ROI did not enter that the patient declined an EC on the form.
Action: Admissions staff have been retrained on filling out the form completely and identifying the person, agency, or organization to whom the disclosure would be made. The form for Client # 2 was corrected on May 13, 2025.
Monitoring: Monitoring will be completed monthly by the Director of Admissions/Designated Staff and monitored by the Director of PI during monthly chart audits to establish compliance with identifying the person, agency, or organization to whom the disclosure would be made on the ROI. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
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.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of two applicable client records reviewed.
Client # 7 was admitted to the inpatient non-hospital detoxification activity on November 26, 2024 and was involuntarily terminated on November 27, 2024. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from treatment at the project.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Identification of Failure: Client #7 was involuntary discharged from the facility on November 27, 2024, and refused to participate in the discharge process or accept any discharge documents at the time of discharge. The counselor failed to complete the involuntary termination note in the EMR.
Action: All counselors and supervisory staff were re-educated on the requirement to complete the Involuntary Termination Note in the EMR, regardless, if the patient refuses to participate in the discharge process and/or refuses to accept any discharge documents.
Monitoring: Monitoring will be completed monthly by the Clinical Director/Designated Staff and monitored by the Director of PI during monthly chart audits to establish compliance with completing the Involuntary Termination Note in the EMR, regardless, if the patient refuses to participate in the discharge process and/or refuses to accept any discharge documents. Due to a relatively low number of involuntary terminations each month, any patients that are involuntarily discharged will have their chart audited each month to assure compliance completing the Involuntary Termination Note that describes the reason for the termination with a goal of 100% compliance for 3 months. |
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.
|
Observations
Based on a review of client records, the facility failed to provide the client an opportunity to request reconsideration of a decision terminating treatment in one of two applicable client record reviewed.
Client # 7 was admitted to the inpatient non-hospital detoxification activity on November 26, 2024 and was involuntarily terminated on November 27, 2024. There was no documentation, in the record, indicating the client was given the opportunity to request reconsideration of the involuntary termination from treatment at the project.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Identification of Failure: Client #7 was involuntary discharged from the facility on November 27, 2024, and refused to participate in the discharge process or accept any discharge documents at the time of discharge. The counselor failed to complete the involuntary termination note in the EMR which provides notice that the client has the right to appeal the decision to be involuntarily terminated.
Action: All counselors and supervisory staff were re-educated on the requirement to complete the Involuntary Termination Note in the EMR, regardless, if the patient refuses to participate in the discharge process and/or refuses to accept any discharge documents.
Monitoring: Monitoring will be completed monthly by the Clinical Director/Designated Staff and monitored by the Director of PI during monthly chart audits to establish compliance with completing the Involuntary Termination Note in the EMR, regardless, if the patient refuses to participate in the discharge process and/or refuses to accept any discharge documents. Due to a relatively low number of involuntary terminations each month, any patients that are involuntarily discharged will have their chart audited each month to assure compliance with notifying the client of their right to appeal the decision to be involuntarily terminated with a goal of 100% compliance for 3 months. |