INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 3, 2010 through May 4, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on May 20, 2010.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the agency manual during the onsite inspection, the facility failed to document a training procedure which included who is responsible for the completion of the training plan and the time frames for the required components.
The findings include:
The agency training policy and procedure was reviewed during the annual licensing inspection on May 3 and 4, 2010. The procedure did not document who, by job title is responsible for the completion of the overall annual training plan, assessments and the mechanism to collect feedback. The procedure did not document the time frames for completion for each of the required components of the staff development program.
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Plan of Correction
Policy is now updated to reflect the procedure of Executive Director and/or designee to oversee completion of training plan. Assessment of training needs will be collected via surveys to be completed by staff and will be monitored by Exec Dir. Collecting feedback will be done by staff completing evaluation forms post trainings and will be turned in to be monitored by Exec Dir or designee. The time frames are now noted and will take place annually by calendar year. Steps to ensure that deficiency does not recur include Exec Dir using an online calendar with pre-set reminders to ensure procedure/process is carried out each year in a timely fashion. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director, the facility failed to document an assessment of staff training needs in eight of sixteen client records.
The findings include:
Sixteen personnel records were reviewed on May 3, 2010 and May 4, 2010. Also, on May 3 and 4, 2010, the policy and procedure manual was reviewed. In accordance with facility policy and procedure, the facility failed to indicate a time frame when the staff training needs assessment forms will be distributed to each employee. Sixteen employee records were reviewed. Eight client records failed to document the completion of a staff training needs assessment for the January - December 2010 training year, specifically staff records # 1, 2, 3, 4, 5, 9, 10 and 15.
The project/facility director was interviewed on May 4, 2010. The project/facility director confirmed that an assessment of staff training needs was not available for staff records # 1, 2, 3, 4, 5, 9, 10 and 15.
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Plan of Correction
Exec Director will ensure all training plans are completed and turned in in a timely fashion on an annual basis. There will be a tracking system in place via Excel Spreadsheet to ensure this. This will be monitored by Exec Director. Time frame for completion of assesment is by Jan 20 of each calendar year for the upcoming annual training plan year. For indiv training assessments, staff are expected to turn in training certificates with feedback forms within 2 business days of completing training. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of facility policy and procedure and an interview with the project/facility director, the facility failed to document an overall plan for addressing training needs.
The findings include:
On May 3 and 4, 2010, policy and procedures were reviewed. Per the agency policy and procedure, there was no documentation of a time frame that indicated when the overall training plan should be completed. Additionally, the facility failed to document the completion of an overall training plan.
The project/facility director was interviewed on May 4, 2010. The project/facility director confirmed that a plan for addressing training needs of staff was not completed.
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Plan of Correction
Executive Director will indicate time frame for overall training plans by updating the policy to reflect this. Overall Training Plan has been completed for upcoming year and will be completed by January 20 of each calendar year for upcoming year. This process will be monitored by Exec Dir. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the employee training records and the facilities policy and procedure manual, the facility failed to document a individual training plan in nine of sixteen records reviewed.
The findings include:
Sixteen personnel records were reviewed on May 3, 2010 and May 4, 2010. Individual training plans were required in sixteen records reviewed. Per the facility's policy and procedure, individual training plans will be developed with the employee by January 31 of each training year January 1 through December 31. Employee #1 was hired on 5/12/00 and did not have documentation of an individual training plan. Employee #2 was hired on 8/25/03 and did not have documentation of an individual training plan. Employee #3 was hired on 9/26/07 and did not have documentation of an individual training plan. Employee #4 was hired on 7/6/04 and did not have documentation of an individual training plan. Employee #5 was hired on 8/10/09 and did not have documentation of an individual training plan. Employee #9 was hired on 11/19/07 and did not have documentation of an individual training plan. Employee #10 was hired on 12/3/08 and did not have documentation of an individual training plan. Employee #12 was hired on 1/1/10 and did not have documentation of an individual training plan. Employee #15 was hired on 5/11/09 and did not have documentation of an individual training plan.
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Plan of Correction
All employees will have a training plan. If they are hired in during the training year, they will be issued a training plan at their hire date. The next training plan thereafter will be completed by January 20 of the calendar year. All other employees will have their training plans completed by January 20 of the calendar year and this process will be monitored by the Executive Director. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Sixteen personnel records were reviewed on May 3, 2010 and May 4, 2010. There was no documentation of HIV/AIDS and TB/STD training in two employee records. Of the two one was to have HIV/AIDS and TB/STD training within the first year of employment and the other one was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #10 was hired December 3, 2008 and was required to have HIV/AIDS & TB/STD training by December 3, 2009. There was no documentation of TB/STD training in the employee's record as of May 4, 2010.
Employee #16 was hired April 8, 2008 and was required to have HIV/AIDS & TB/STD training by April 8, 2010. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of May 4, 2010.
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Plan of Correction
All employees will have HIV and TB/STD within appropriate time frames. Employee #16 and Employee #10 have been instructed to have their trainings completed by June 30. A tracking system is used to track training times and will be more closely monitored by Exec Dir to ensure time frames are met for all required trainings. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection and a staff interview, the facility failed to maintain documentation of a hot food log to determine if the temperatures are at or above 140F.
The findings include:
The physical plant inspection took place on May 4, 2010. The facility did not have a log book for the documentation of hot food temperatures. An interview with staff confirmed that the facility did not maintain a log for the documentation of hot food temperatures during the physical plant inspection.
Additionally, the facility's policy and procedure was not consistent with regulatory requirements, the facility's policy and procedure manual stated that the freezer must be maintained at 0-10F and the refrigerator at 40-45F. The facility's policy and procedure regarding food temperatures was confirmed by the project/facility director during the physical plant tour.
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Plan of Correction
Dietary policies have been updated to reflect appropriate temperatures. A food temperature log has been developed and is maintained by Dietary Manager and/or designee to ensure hot food temperatures are within appropriate range. The procedure will be monitored by Exec Dir to ensure this is completed on a daily basis. |
709.24(a)(1) 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:
(1) Defined target population.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to document the facility's defined target population.
The findings include:
The policy and procedure manual was reviewed on May 3, 2010 and May 4, 2010. The facility failed to designate the target population in their policy and procedures. An interview on May 4, 2010 with the project/facility director confirmed that the policy was not in place.
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Plan of Correction
Policy has been updated to reflect facility's target population. This was completed by Exec Dir. The policy will be reviewed annually by Exec Dir and will be documented in the manual each year to ensure the policy does reflects a target population. Should the target pop change, the policy will be revised to relects such by the exec dir. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a tour of the facility, the facility failed to post the service fee schedule in a prominent place.
The findings include:
The physical plant inspection took place on May 4, 2010 at approximately 9:30 AM. During the tour of the lobby area, it was reported by facility staff that the fee schedule was posted in this area. The licensing specialists were unable to locate the fee schedule in the area identified and an interview with the project/facility director confirmed that the fee schedule was not posted during the physical plant inspection.
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Plan of Correction
Fee schedule has been posted in the lobby. Exec Dir will check weekly to ensure it is in place in case it is taken down by someone. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the consent to release information forms to the funding sources exceeded 4 Pa. Code Subsection 255.5(b) and 4 Pa. Code Subsection 255.5(a)(6) in thirteen of thirteen patient records.
The findings include:
Based on the review of client records on May 5, 2010, the facility failed to ensure that the information disclosed to funding source did not exceed 4 Pa Code Subsection 255.5 (b) in thirteen records reviewed. In client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 the facility documented the release of the client face sheet to the insurance company. The face sheet had the following information that exceeded 255.5 (b): treatment history, emergency contact, medical history, medications, psychiatric history, living situation, and legal information.
Additionally in client record # 8, during a family session dated 4/23/10 with client # 8's father and mother, the facility did not have a consent to release information to the client's father.
In client record #10, the consent to release forms to client # 10's parole officer, dated
4/25/10 and 4/27/10, exceeded 255.5 as it was documented the facility would provided the client's aftercare plan and treatment plan to the parole officer. Also, the consent to release form, dated 4/27/10, did not include the client's signature or documentation that a copy of the consent to release form had been offered to the client.
Client record #11 contained a consent to release form, dated 1/4/10, that failed to document that the client was offered a copy of the consent to release form. Also, another consent to release form, also dated 1/4/10, did not document the date when it was signed by the client nor did it designate that the patient was offered a copy of the consent to release form.
Client record#13 contained a consent to release form, dated 12/16/09, to the client's employer that exceeded 255.5 by allowing the release of the client's diagnosis and the nature of the project. The employer is only allowed to be informed whether or not the client is in treatment.
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Plan of Correction
Consent for Release of Information will indicate Face Sheet, Page 1 to ensure there are no excess information being released. All staff, especially clinical, have been educated on importance of obtaining consents from patients any time any information is released during a clinical case conference team meeting. All staff have been educated on obtaining indication from patients on whether they want a copy of the form. This has been and will be monitored by Exec Dir for assurance of continued compliance. Pts will re-sign updated consents to ensure confidentiality is not exceeded. The consents will be updated to relect face sheet = page 1 only. All new pts will sign the updated consent forms. This will be monitored and ensured by the Exec Dir. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to completely document psychosocial evaluations in six of seven rehabilitation client records reviewed.
The finding includes:
Thirteen records were reviewed on May 5, 2010. Psychosocial evaluations were required in thirteen records reviewed. Seven of the thirteen records reviewed were rehabilitation clients; six of the client records failed to document completed psychosocial evaluations.
Client record #7 failed to include documentation of the the client's asset and strengths and the client's negative factors that might inhibit treatment.
Client record #9 failed to include documentation of the client's assets and strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions and impressions.
Client record #10 failed to include documentation of the the client's problems and needs, assets and strengths, support systems, coping mechanisms, clients negative factors that might inhibit treatment and the counselor conclusions and impressions.
Client record #11 failed to include documentation of the client's assets and strengths, coping mechanisms and the counselor conclusions and impressions.
Client record #12 failed to include documentation of the client's problems and needs, assets and strengths, support systems, coping mechanisms, clients negative factors that might inhibit treatment and the counselor conclusions and impressions.
Client record #13 failed to document the client's problems and needs, assets and strengths, support systems, coping mechanisms and the counselor conclusions and impressions.
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Plan of Correction
Clinical staff were provided an inservice during clinical case conference team meeting to review importance of psychosocial evaluations and what it means to document all areas of clinical formulations. To monitor for improvment, clinical supervisor(s) have been instructed by Exec Dir to ensure all evaluations are done completely. If they are not, counselors are to be educated one on one. This process is monitored by Exec Dir. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document timely individual treatment plans in three of seven rehabilitation client records reviewed.
The finding includes:
Thirteen records were reviewed on May 5, 2010. Individual treatment plans were required in thirteen records reviewed. Seven of the thirteen records reviewed were rehabilitation clients and of those seven that were required to have individual treatment plans three were not completed within the required time per the facility's policy and procedure manual. The facility's policy and procedure manual stated that individual treatment plans will be completed within 72 hours from the client's admission date.
Client record #7 was admitted on 4/8/10 and their individual treatment plan was not developed until 4/18/10.
Client record #11 was admitted on 12/9/09 and their individual treatment plan was not developed until 12/24/09.
Client record #13 was admitted on 12/15/09 and their individual treatment plan was not developed until 12/31/09.
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Plan of Correction
Treatment plan policy will be adjusted to reflect a new time frame which will be 4 working days from time of patient admission to the completion of treatment plans to allow for time for assessment of patient needs. Clinical staff will be educated of this change and will be monitored via daily chart checks. This process will be monitored by the Exec Dir. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans in three of seven rehabilitation client records reviewed.
The finding includes:
Thirteen records were reviewed on May 5, 2010. Aftercare plan were required in six records reviewed. Seven of the thirteen records reviewed were rehabilitation clients and out of those seven rehabilitation client records, three were rehabilitation discharge records that were required to have aftercare plans. Per the facilities policy and procedure manual aftercare plans will be developed on every client prior to their discharge from the facility. Also, the facility did not document individual goals with time frames for each discharge client.
Client record #11 was admitted on 12/9/09 and discharged on 1/6/10. The client's aftercare plan was not completed until 1/11/10.
Client record #13 was admitted on 12/15/09 and discharged on 1/14/10. The client's aftercare plan was not completed until 1/15/10.
All aftercare plans were marked or documented for every client with the following information:
1. Follow up with Primary Care Physician for routine medical care, health maintenance and prescription refills.
2. Repeat Liver Function Tests in 4 to 6 weeks
3. Repeat Cholesterol Level with Lipid Profile in 1 to 8 weeks
4. Other, to include routine GYN Care/Colon Rectal Screening with Primary Care Provider
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Plan of Correction
Aftercare Plans will be modified to allow for individualised information to be indicated by clinical staff for each patient. All patients will be presented with indiv goals on their aftercare plan. Clinical staff will be educated and trained in this new process. This will be monitored via chart checks under the direction and supervision of the Exec Dir. All counselors will ensure aftercare plans are done by the day before pt's DC date. This will be monitored by Clin Supv reviewing all charts of pts up for DC the following day to ensure AC plan is complete. If it it determined that AC is not completed or individualised, counselor will need to review this and correct this. If problem persists with specific clinical staff person, a team meeting will be scheduled with exec dir and clin supv and is noted adverse consequences could occur w/ position. |