INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 3, 2010 through May 4, 2010 licensure renewal inspection. The follow-up inspection was conducted on November 16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 11, 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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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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(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
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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Plan of Correction
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 assistants and within two years of the date of hire date for all other staff.
The findings include:
Sixteen personnel records were reviewed on November 16, 2010. There was no documentation of HIV/AIDS and TB/STD training in one employee record.
Employee #1 was hired April 8, 2008 and was required to have HIV/AIDS & TB/STD training by April 8, 2010. There was no documentation of TB/STD training in the employee's record as of November 16, 2010.
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Plan of Correction
Employee 1 is scheduled to attend TB-STD training on December 11. It is presented by a BDAP trainer and is 4 hours long. Executive Director will ensure attendance and will be documented via Training Certificate.All employees will be tracked by a spreadsheet and given reminders to ensure timely attendance at the trainings as required. |
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 inspection of the food temperature log and a staff interview, the facility failed to maintain documentation of a hot food log and cold temperature logs to determine if the temperatures are at or above 140F or below 40F and frozen food below 0F.
The findings include:
The inspection of the food temperature log took place on November 16, 2010. The facility didn't have an updated log book for the documentation of hot food temperatures since May 28, 2010. There was one documentation of November 16, 2010 and that was the day of the unannounced follow-up on November 16, 2010. The last cold food temperature log documentation was in August 2010. An interview with facility director confirmed that the facility did not maintain an updated log for the documentation of hot and cold food temperatures.
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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. |
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 licensing specialist observation, November 16, 2010 at around 10 am, a heater that was not permanently mounted or installed was found in an office.
The findings include:
This licensing specialist observed a space heater that was not permanently attached during the performance of duties on November 16, 2010. The heater was found in an admission's office on the first floor of the facility. The facility director was notified and the heater was removed.
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Plan of Correction
All space heaters are removed. All heaters will be mounted. This will be monitored by Maintenance Manager and Executive Director. |
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 eight of eight patient records.
The findings include:
Based on the review of client records on November 16, 2010, the facility failed to ensure that the information disclosed to a funding source did not exceed 4 Pa Code Subsection 255.5 (b) in eight records reviewed. In client records # 1, 2, 3, 4, 5, 6, 7 and 8 the facility documented that they had released the client face sheet to the insurance company. The face sheet contained the following information that exceeded 255.5 (b): treatment history, emergency contact, medical history, medications, psychiatric history, living situation, and legal information.
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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 seven of eight rehabilitation client records reviewed.
The finding includes:
Eight records were reviewed on November 16, 2010. Psychosocial evaluations were required in eight records reviewed. Seven of the eight client records failed to document completed psychosocial evaluations.
Client record #1, 3, 4, 5, 6, 7 and 8 failed to include documentation of the the client's asset and strengths, support systems, coping mechanisms, client's negative factors that might inhibit treatment and the counselor's 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 six of eight rehabilitation client records.
The findings include:
Eight records were reviewed on November 16, 2010. Individual treatment plans were required in eight records reviewed. 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 #2 was admitted on 9/19/10 and their individual treatment plan was not developed until 9/22/10.
Client record #3 was admitted on 9/5/10 and their individual treatment plan was not developed until 9/18/10.
Client record #4 was admitted on 8/27/10 and their individual treatment plan was developed on 8/29/10 and their psychosocial evaluation completed a day later 8/30/10.
Client record #5 was admitted on 7/20/10 and their individual treatment plan was not developed until 7/26/10.
Client record #6 was admitted on 9/4/10 and their individual treatment plan was not developed until 9/7/10.
Client record #7 was admitted on 9/21/10 and their individual treatment plan was not developed until 9/24/10.
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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 eight of eight rehabilitation client records reviewed.
The findings include:
Eight records were reviewed on November 16, 2010. Aftercare plan were required in eight records reviewed. 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.
In records #1, 2, 3, 4, 5, 6, 7 and 8 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. |