INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 2021 through November 4, 2021 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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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies in two of eight personnel records reviewed.Employee # 1 was hired as the Project Director on January 11, 2021. The emergency preparedness training was not provided as of the date of inspection.Employee # 2 was hired as the Facility Director on January 11, 2021. The emergency preparedness training was not provided as of the date of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Emergency preparedness trainings were not provided for the Project Director and the Facility Director.
Action: HR department will send training requirement reminders to all staff members and their supervisors prior to the required deadlines. Employee #1 and Employee #2 have received their emergency preparedness trainings.
Monitoring: Compliance rates with staff training requirements will be tracked by trended by the Director of HR. A tracking grid will be maintained to ensure trainings are scheduled and completed within the required timeframe. The compliance rates will be monitored by the PI committee until 100% compliance has been reached for 3 months. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed.Client # 6 was admitted to the detox level of care on May 27, 2021 and was discharged on June 1, 2021. A release of information form to the funding source was signed and dated by the client and witness on May 27, 2021, that allowed for the release of the entire record, which exceeds the limits established by 4 Pa. Code 255.5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Issue corrected June 1, 2021
Identification of Failure: Release of information signed by client and witness allowed for the entire record to be released prior to the identification of this deficiency in June 2021
Action: The funding source ROI consent for was updated in our EMR to limit the release of information within the limits of 4 Pa. Code 255.5 (b) in June of 2021.
Monitoring: The quality department will continue to track information released to ensure it falls within standards of compliance regarding confidentiality guideline 709.28 (c). Monitoring be reported to the PI committee and will continue until 100% compliance for 3 consecutive months is reached. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop and implement policies and procedures pertaining to inspection of storage areas that ensure compliance with State and Federal law and program policy, which is to include that copies of drug-related regulations are available in appropriate areas.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure:
Drug-related regulations are not available in appropriate areas.
Action:
Policy MM 111 was updated to include this standard. Copies of drug-related regulations will be posted and available in medication storage areas to ensure compliance with State and Federal law and program policy.
Monitoring: Inspections of medication storage units will be conducted to ensure drug-related references are accessible until 100% compliance is reached for 3 months consecutive.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in two of four applicable client records reviewed.Client # 6 was admitted to the detoxification level of care on May 27, 2021 and was discharged on June 1, 2021. The written procedure manual stated that follow-up will be completed within 7 days of discharge. There was no follow-up information documented in the client record as of the date of the inspection.Client # 7 was admitted to the detoxification level of care on June 29, 2021 and was discharged on July 4, 2021. The written procedure manual stated that follow-up will be completed within 7 days of discharge. There was no follow-up information documented in the client record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: This deficiency was identified by the facility in July and has been in compliance since that time.
Action:
Malvern Treatment Centers designated staff member to coordinate the follow-up call tracking system as of July 2021. The tracking grid is updated daily and follow up calls tracked.
Monitoring:
Monitoring of follow-up calls will be conducted monthly to ensure compliance. Monthly reporting of follow-up documentation compliance will continue until 100% compliance is met for 3 consecutive months. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to assure that treatment and rehabilitation plans are reviewed and updated at least every 15 days for those projects whose client treatment regime in less than 30 days in three of seven client records reviewed.Client # 10 was admitted to the residential level of care on October 15, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on October 18, 2021 and the next update was due no later than November 2, 2021; however, the update was not completed at the time of inspection.Client # 12 was admitted to the residential level of care on July 27, 2021 and was discharged on August 17, 2021. The comprehensive treatment plan was completed on July 29, 2021 and the next update was due no later than August 13, 2021; however, the update was not completed at the time of discharge. Client # 13 was admitted to the residential level of care on September 5, 2021 and was discharged on September 24, 2021. The comprehensive treatment plan was completed on September 7, 2021 and the next update was due no later than September 22, 2021; however, the update was not completed at the time of discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The treatment plan update was not completed within 15 days of the completion of the comprehensive treatment plan.
Action:
The Clinical Director has scheduled a clinical staff training to review the requirements of treatment plan updates and timeliness of documentation 11/23/2021.
Monitoring:
Monitoring of treatment plan updates is part of the facility monthly and quarterly audits. Findings are reported to the facility PI committee. the quality department will track regulatory standards of compliance regarding treatment plan update guidelines. Tracking will continue until 100% compliance for 3 consecutive months is reached. |