INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2012 to May 16, 2012 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:
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Plan of Correction
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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 the facility's training records, the facility failed to document an overall training plan to address agency staff training needs.
The findings include:
On May 14, 2012 the facility's training records were reviewed for documentation of an overall agency training plan. The facility did not document an overall training plan for the 2012 training year.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
An overall training plan was developed for 2012 however it did not meet all the requirements listed in this standard. The 2012 overall training will be revised and updated to ensure all licensing requirements are met. The training plan will be revised by June 30, 2012. To ensure future compliance with this standard the 2013 overall training plan will be devleoped by January 15, 2013 and submitted tot he Regulatory Compliance Manager for review. |
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 personnel records and the facility's Staffing Requirements Facility Summary Report form, the facility failed to develop an individual training plan the beginning of their training year and/or document a date of completion for an individual training plan. Also, based on a review of the facility's Staffing Requirements Facility Summary Report form, the facility failed to document an individual training plan.
The findings include:
On May 14, 2012 through May 15, 2012, ten personnel records requiring documentation of an individual training plan were reviewed. Also, on May 14, 2012 through May 15, 2012, the Staffing Requirements Facility Summary Report form was reviewed to verify that employees had received an individual training plan. The facility did not document an individual training plan the beginning of their training year in seven of ten personnel records reviewed, specifically, personnel records # 1, 2, 3, 4, 5, 10, and 11. The facility also did not document a date of completion for an individual training plan in three of ten personnel records reviewed, specifically, personnel records # 8, 9, and 14. In addition, based on the Staffing Requirements Facility Summary Report form, the facility did not document an individual training plan for employees, specifically, employees # 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 33, 34, 35, 36, 37, 38, and 39. Also, based on the Staffing Requirements Facility Summary Report form, the facility did not document an individual training plan the beginning of their training year for an employee, specifically, employee # 40.
Employee # 1, the project director, was hired May 1, 2010. The individual training plan for employee # 1 was due January 31, 2012. However, the facility did not document an individual training for employee # 1 until April 28, 2012.
Employee # 2, the facility director, was hired August 1, 2011. The individual training plan for employee # 2 was due January 31, 2012. However, the facility did not document an individual training for employee # 2 until April 28, 2012.
Employee # 3, a clinical supervisor, was initially hired March 30, 2009 and was hired for his current position August 1, 2011. The individual training plan for employee # 3 was due January 31, 2012. However, the facility did not document an individual training for employee # 3 until April 28, 2012.
Employee # 4, a clinical supervisor, was initially hired August 25, 2003 and was hired for his current position March 20, 2006. The individual training plan for employee # 4 was due January 31, 2012. However, the facility did not document an individual training for employee # 4 until May 2, 2012.
Employee # 5, a counselor, was hired July 28, 2011. The individual training plan for employee # 5 was due January 31, 2012. However, the facility did not document an individual training for employee # 5 until April 26, 2012.
Employee # 8, a counselor, was hired April 11, 2012. The individual training plan for employee # 8 was due May 11, 2012. The individual training plan for employee # 8 was completed; however, the individual plan did not include a date of completion.
Employee # 9, a counselor, was hired March 28, 2012. The individual training plan for employee # 9 was due April 27, 2012. The individual training plan for employee # 9 was completed; however, the individual plan did not include a date of completion.
Employee # 10, a counselor, was hired September 1, 2008. The individual training plan for employee # 10 was due January 31, 2012. However, the facility did not document an individual training for employee # 10 until April 26, 2012.
Employee # 11, a counselor, was hired November 26, 2011. The individual training plan for employee # 11 was due January 31, 2012. However, the facility did not document an individual training for employee # 11 until April 27, 2012.
Employee # 14, a counselor assistant, was hired May 5, 2009. The individual training plan for employee # 14 was due January 31, 2012. The individual training plan for employee # 14 was completed; however, the individual plan did not include a date of completion.
Employee # 15, the Assistant Director of Nursing, was hired February 12, 2007. The individual training plan for employee # 15 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 15.
Employee # 16, a nurse, was hired May 20, 2003. The individual training plan for employee # 16 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 16.
Employee # 17, a nurse, was hired March 15, 2006. The individual training plan for employee # 17 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 17.
Employee # 18, a nurse, was hired May 26, 2008. The individual training plan for employee # 18 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 18.
Employee # 19, a nurse, was hired February 21, 2009. The individual training plan for employee # 19 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 19.
Employee # 20, a nurse, was hired April 7, 2009. The individual training plan for employee # 20 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 20.
Employee # 21, a nurse, was hired July 13, 2009. The individual training plan for employee # 21 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 21.
Employee # 22, a nurse, was hired August 16, 2011. The individual training plan for employee # 22 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 22.
Employee # 23, a nurse, was hired October 7, 2011. The individual training plan for employee # 23 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 23.
Employee # 24, a nurse, was hired February 27, 2012. The individual training plan for employee # 24 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 24.
Employee # 25, a nurse, was hired September 28, 2011. The individual training plan for employee # 25 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 25.
Employee # 26, a nurse, was hired July 27, 2011. The individual training plan for employee # 26 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 26.
Employee # 27, a nurse, was hired July 25, 2011. The individual training plan for employee # 27 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 27.
Employee # 27, a nurse, was hired July 25, 2011. The individual training plan for employee # 27 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 27.
Employee # 28, a nurse, was hired October 11, 2011. The individual training plan for employee # 28 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 28.
Employee # 29, a nurse, was hired August 8, 2011. The individual training plan for employee # 29 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 29.
Employee # 30, a nurse, was hired March 7, 2012. The individual training plan for employee # 30 was due April 6, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 30.
Employee # 32, a nurse, was hired September 28, 2009. The individual training plan for employee # 32 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 32.
Employee # 33, a nurse, was hired April 6, 2005. The individual training plan for employee # 33 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 33.
Employee # 34, a nursing assistant, was hired October 5, 2010. The individual training plan for employee # 34 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 34.
Employee # 35, a nursing assistant, was hired March 23, 2009. The individual training plan for employee # 35 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 35.
Employee # 36, a nursing assistant, was hired July 22, 2009. The individual training plan for employee # 36 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 36.
Employee # 37, a recovery educator, was hired November 16, 2009. The individual training plan for employee # 37 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 37.
Employee # 38, a recovery educator, was hired January 10, 2011. The individual training plan for employee # 38 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 38.
Employee # 39, a psychiatrist, was hired February 16, 2000. The individual training plan for employee # 39 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 39.
Employee # 40, a shift supervisor, was hired September 20, 2011. The individual training plan for employee # 40 was due January 31, 2012. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, the facility did not document an individual training plan for employee # 40 until May 10, 2012.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 15, 2012 at approximately 3:00 P.M.
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Plan of Correction
Training Plans will be completed for all employees for the 2012 training year by July 6, 2012.
A database has been created to track the completion of training plans for all employees. This database will be updated and reviewed on a weekly basis. Monthly the Regulatory Compliance Manager will review training files and the databse to ensure continued compliance. |
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/or the facility's Staffing Requirements Facility Summary Report form, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two year of employment for all other staff.
The findings include:
On May 14, 2012 through May 15, 2012, five personnel records requiring documentation of a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training were reviewed to verify that employees had received HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. Also, on May 14, 2012 through May 15, 2012, the Staffing Requirements Facility Summary Report form was reviewed to verify that employees had received HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility did not ensure that staff received HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff in one of five personnel records reviewed, specifically, personnel record # 1. Also, based on the Staffing Requirements Facility Summary Report form, the facility did not ensure that support staff received STD/TB training within two years of employment, specifically, employee # 35.
Employee # 1, the project director, was hired May 1, 2010. Employee # 1 was due to complete HIV/AIDS and STD/TB training by May 1, 2012. However, personnel record # 1 did not include documentation of HIV/AIDS and STD/TB training as of May 15, 2012.
Employee # 35, a nursing assistant, was hired March 23, 2009. Employee # 35 was due to complete STD/TB training by March 23, 2011. However, based on the facility's Staffing Requirements Facility Summary Report form completed on May 11, 2012, employee # 35 has not completed STD/TB training.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 15, 2012 at 3:00 P.M.
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Plan of Correction
All employees who have not attended BDAP/s HIV/AIDS and TB/STD will attend these courses as they are offered in our region. All employees who still need thses trainings will attend these trainings by August 31, 2012.
A database has been created to monitor the completion of all required trainings for all employees. This database will be reviewed weekly to ensure all employees in need of the required trainings are scheudled to attend the trainings. Monthly the Regulatory Compliance Manager will review training files to enusre employees are recieving the requried trainings by the requried the completion dates. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed 25 clock hours of required training.
The findings include:
On May 14, 2012 and May 15, 2012, two personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 10.
Employee # 10, a counselor, was hired on September 1, 2008. The facility's training year is from January 1, 2011 to December 31, 2011. Employee # 10's personnel record only had documentation of 15 clock hours of training for the January 1, 2011 to December 31, 2011 training year as of May 15, 2012.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 15, 2012 at approximately 3:00 P.M.
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Plan of Correction
The employee's who failed complete the required number of training hours will be counseled by their supervisor. This counseling will be documented.
A database has been created to monitor the completion of training hours for all counselors and counselor assistants. Monthly reports will be generated from the database indicating each counselor/counselor assitants current training completion. The Clinical Supervisors will then meet with their counselor/counselor assitants to review the employees training completion. Any employee who is not attending training on a regular basis in order to attain the required number of training hours will receive disciplinary action and follow up. The Regulatory Compliance Manager will meet with the Clinical Supervisors on a Monthly basis to ensure all counselors/counselor assistants are making progress toward their required number of training hours. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor assistant completed 40 clock hours of training the first year and 30 clock hours annually thereafter.
The findings include:
On May 14, 2012 and May 15, 2012, one personnel record requiring 30 clock hours of training was reviewed. The facility failed to provide documentation of 30 clock hours of training in one of one personnel record, specifically, personnel record # 14.
Employee # 14, a counselor assistant, was hired on May 5, 2009. The facility's training year is from January 1, 2011 to December 31, 2011. Personnel record # 14 did not include documentation of training hours for the January 1, 2011 to December 31, 2011 training year as of May 15, 2012.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 15, 2012 at approximately 3:00 P.M.
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Plan of Correction
The employee's who failed complete the required number of training hours will be counseled by their supervisor. This counseling will be documented. A database has been created to monitor the completion of training hours for all counselors and counselor assistants. Monthly reports will be generated from the database indicating each counselor/counselor assitants current training completion. The Clinical Supervisors will then meet with their counselor/counselor assitants to review the employees training completion. Any employee who is not attending training on a regular basis in order to attain the required number of training hours will receive disciplinary action and follow up. The Regulatory Compliance Manager will meet with the Clinical Supervisors on a Monthly basis to ensure all counselors/counselor assistants are making progress toward their required number of training hours.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observations on May 15, 2012, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
The findings include:
A physical plant inspection was conducted on May 15, 2012. It was observed during the inspection from approximately 12:25 P.M. to 12:26 P.M., that there were areas of the concrete walls in one of the storage rooms in the basement that had cracking concrete, crumbling concrete, and chipping concrete.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager and facility director on May 15, 2012 at 12:26 P.M.
This is a repeat citation. The facility was cited on October 5, 2011 and May 18, 2011 for noncompliance with this standard.
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Plan of Correction
The concrete wall in the storage areas of the basement have been repaired. These repairs were completed on June 9, 2012. Physical Plant inspection rounds will be conducted on a monthly basis for a period of three month starting in July. Starting in October the physical plant inspection rouns will be completed quarterly. These inspection rounds will monitor the conditions of the physical plant to ensure the facility is kept clean, safe, sanitary and in good repair at all times. The physical plant inspection rounds will be completed by the Maintenance Manager and forwarded to the Regulatory Compliance Manager for review. All issues identified during the physical plant inspection rounds will be repaired as soon as possible following the inspection rounds. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on observations on May 15, 2012, the facility failed to ensure that storage areas for foods are free of food particles, dust and dirt.
The findings include:
A physical plant inspection was conducted on May 15, 2012. It was observed during the inspection from approximately 12:21 P.M. to 12:23 P.M., that there were areas of spilled food particles on the floor in the dry storage room in the basement.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager and facility director on May 15, 2012 at 12:23 P.M.
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Plan of Correction
The spilled food particles were cleaned up immediately and the food service staff were reminded of the safety and sanitation regulations for food storage. Weekly saniation and safety inspections of the food service storage areas will be conducted starting in July to ensure all regulations are met. These inspections will be completed by the Maintenance Manager and forwarded tot he Regulatory Compliance Manager for review and follow-up. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observations on May 15, 2012, the facility failed to light interior exits and stairs at all times.
The findings include:
A physical plant inspection was conducted on May 15, 2012. It was observed during the inspection at approximately 12:30 P.M., that there were areas of the interior emergency exit stairs near the oil tank room that were not lighted. It was also observed during the inspection at approximately 12:32 P.M., that there were areas of the interior emergency exit stairs near the maintenance office that were not lighted.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager and facility director on May 15, 2012 at approximately 12:32 P.M.
This is a repeat citation. The facility was cited on May 18, 2011 for noncompliance with this standard.
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Plan of Correction
All light bulbs and lights in emergency exit stairwells will be replaced and/or repaired by 6/22/12. Physical Plant inspection rounds will be conducted on a monthly basis for a period of three month starting in July. Starting in October the physical plant inspection rounds will be completed quarterly. These inspection rounds will monitor the emergency exit lights. The physical plant inspection rounds will be completed by the Maintenance Manager and forwarded to the Regulatory Compliance Manager for review. All issues identified during the physical plant inspection rounds will be repaired as soon as possible following the inspection rounds. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
Fire drill records were reviewed on May 14, 2012. The records were reviewed from the period covering June 2011 to April 2012. The facility did not have documentation of an unannounced fire drill in four of eleven months reviewed, specifically, June 2011, July 2011, August 2011, and September 2011.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 14, 2012 at approximately 11:00 A.M.
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Plan of Correction
Fire drills were not held during the months of June, July, August and September of 2011. Fire drills have been completed on a monthly basis every month since October 2011. Fire drills will continue to be completed on a monthly basis. Currently the Regulatory Compliance Manager monitors the completion of monthly fire drills. This monitoring will continue. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
Fire drill records were reviewed on May 14, 2012. The records were reviewed from the period covering June 2011 to April 2012. The facility's sleeping hours are from 11:00 P.M. to 7:00 A.M. The facility was due to have a fire drill during sleeping hours on or before December 2011. However, a fire drill during sleeping hours was not documented by the facility until January 30, 2012.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 14, 2012 at approximately 11:00 A.M.
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Plan of Correction
Fire drills were not held during the months of June, July, August and September of 2011. Fire drills have been completed on a monthly basis every month since October 2011. Quarterly a fire drill is being held during sleeping hours. Fire drills will continue to be completed on a monthly basis including completion of a drill during sleeping hours quarterly. Currently the Regulatory Compliance Manager monitors the completion of monthly fire drills. This monitoring will continue. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment.
The findings include:
On May 14, 2012 and May 15, 2012, eight personnel records requiring documentation of fire extinguisher training were reviewed. The facility failed to ensure that they instruct staff in the use of the fire extinguisher upon staff employment in three of eight records reviewed, specifically, personnel records # 7, 8, and 9.
Employee # 7, a counselor, was hired on March 26, 2012. Employee # 7 was due to complete fire extinguisher training upon employment. However, personnel record # 7 did not include documentation of fire extinguisher training as of May 15, 2012.
Employee # 8, a counselor, was hired on April 11, 2012. Employee # 8 was due to complete fire extinguisher training upon employment. However, employee # 8 did not complete fire extinguisher training until May 9, 2012.
Employee # 9, a counselor, was hired on March 28, 2012. Employee # 9 was due to complete fire extinguisher training upon employment. However, employee # 9 did not complete fire extinguisher training until May 9, 2012.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 15, 2012 at approximately 4:00 P.M.
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Plan of Correction
A fire extinguisher training has been developed for all new employees of Malvern. Starting on 5/15/12 all new employees are receiving this training within 7 days of hire. A database has been created to monitor the completion fire extinguisher training within 7 days. This database will be reviewed weekly to ensure all new employees receive fire extinguisher training within 7 days. Monthly the Regulatory Compliance Manager will review training files to ensure all new employees are recieving fire extinguisher training within 7 days of hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
On May 14, 2012 and May 15, 2012, eight personnel records requiring documentation that all personnel on all shifts had been trained to perform assign tasks during emergencies were reviewed. The facility did not ensure that all personnel on all shifts completed emergency training upon employment at the facility in three of eight personnel records reviewed, specifically, personnel records # 7, 8, and 9.
Employee # 7, a counselor currently working at the facility, was hired on March 26, 2012. Employee # 7 was due to complete emergency training prior to working any shifts at the facility. However, personnel record # 7 did not include documentation of emergency training as of May 15, 2012.
Employee # 8, a counselor currently working at the facility, was hired on April 11, 2012. Employee # 8 was due to complete emergency training prior to working any shifts at the facility. However, employee # 8 did not complete emergency training until May 9, 2012.
Employee # 9, a counselor currently working at the facility, was hired on March 28, 2012. Employee # 9 was due to complete emergency training prior to working any shifts at the facility. However, employee # 9 did not complete emergency training until May 9, 2012.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 15, 2012 at approximately 4:00 P.M.
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Plan of Correction
An emergency preparedness training has been developed for all new employees of Malvern. Starting on 5/15/12 all new employees are receiving this training within 7 days of hire. A database has been created to monitor the completion emergency preparedness training within 7 days. This database will be reviewed weekly to ensure all new employees receive emergency preparedness training within 7 days. Monthly the Regulatory Compliance Manager will review training files to ensure all new employees are recieving emergency preparedness training within 7 days of hire. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the administrative records, the facility failed to document and make available to the public an annual report.
The findings include:
On May 14, 2012, the facility's administrative records were reviewed for documentation of their annual report. The facility did not document an annual report for years 2010 and 2011.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
An annual report for the fiscal year ending on June 30, 2012 will be developed and then made available to the public by August 31, 2012. A copy of this reprot will be sent to the Regulatory Compliance Manager for review. Annually the Regulatory Compliance Manager will meet with senior managmeent to ensure the annual reprot is written and made available to the public. This annual meting will occur during the month of June each year. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based the review of the facility's referral letters of agreement, the facility failed to document a written letter of agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written agreement for 24-hour emergency medical coverage.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document work performance evaluations at least annually.
The findings include:
On May 14, 2012 through May 15, 2012, ten personnel records requiring documentation of a work performance evaluation were reviewed. The facility did not document a work performance evaluation at least annually in two of ten personnel records reviewed, specifically, personnel records # 4 and 14.
Employee # 4, a clinical supervisor, was initially hired August 25, 2006 and hired for his current position March 20, 2006. Employee # 4 was due a work performance evaluation by March 20, 2012. However, the most recent documentation of a work performance evaluation for employee # 4 was March 20, 2011.
Employee # 14, a counselor assistant, was hired May 5, 2009. Employee # 14 was due a work performance evaluation by November 5, 2009, May 5, 2010, November 5, 2010, May 5, 2011, November 5, 2011 and another work performance evaluation by May 21, 2012. A work performance evaluation was complete for employee # 14 on May 21, 2010. However, the next work performance evaluation for employee # 14 was not completed until May 15, 2012.
The findings were confirmed during an interview with the Quality/Risk/Regulatory Manager on May 15, 2012 at 3:00 P.M.
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Plan of Correction
Performance Evaluations will be completed for the two employees identified by June 22, 2012.
A database has been created to track the completion of performance evaluations for all employees. This database will be updated and reviewed on a weekly basis. Monthly the Regulatory Compliance Manager will review personnel files and the database to ensure continued compliance with the completion of performance evaluations. |
709.64(c)(1) LICENSURE Medical/dental support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining dental services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining dental services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.64(c)(3) LICENSURE Legal support service
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining legal services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining legal services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.64(c)(4) LICENSURE Economic Support Services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining economic services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining economic services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.64(c)(5) LICENSURE Educational support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining educational services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining educational services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.64(c)(6) LICENSURE Vocational support systems
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining vocational services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining vocational services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services in four of six records reviewed.
The findings include:
On May 15, 2012, treatment plans in six client records were reviewed for documentation type and frequency of treatment and rehabilitation services, specifically records # 1, 2, 3, 4, 5 and 6. The facility did not document type and frequency of treatment and rehabilitation services in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 4/20/12. The treatment plan in client #1's record dated 4/23/11 did not include type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on 4/20/12. The treatment plan in client #2's record dated 4/20/12 did not include type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on 4/16/12. The treatment plan in client #3's record dated 4/17/12 did not include type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on 4/13/12. The treatment plan in client #4's record dated 4/13/12 did not include type and frequency of treatment and rehabilitation services.
An interview with the facility director on May 15, 2012 confirmed the findings.
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Plan of Correction
The electronic medical record will be revised to ensure the type and frequency are indicated for each objective on the treatment plan. All counselors will be trained in the completion of type and frequency on the treatments plans. This training will be documented. The Clinical Supervisors will complete medical record reviews on a weekly basis to monitor the completion of type and frequency on the treatment plans. These reviews will be forwarded to the Regulatory Compliance Manager for review. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include a proposed type of support service in two of six records reviewed.
The findings include:
On May 15, 2012, treatment plans in six client records were reviewed for documentation support services, specifically records # 1, 2, 3, 4, 5 and 6. The facility did not document treatment plans to include a proposed type of support service in client records # 2 and 4.
Client # 2 was admitted on 4/20/12. The treatment plan in client #2's record dated 4/20/12 did not include a proposed type of support service.
Client # 4 was admitted on 4/13/12. The treatment plan in client #4's record dated 4/13/12 did not include a proposed type of support service.
An interview with the facility director on May 15, 2012 confirmed the findings.
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Plan of Correction
The electronic medical record will be revised to include support services in the treatment plans. Counselors will be trained on the completion of support services in the treatment plans. training will be documented. The Clinical Supervisors will complete weekly medical record reviews to monitor the complete of support services on treatment plans. Completed reviews will be forwarded to the Regulatory Compliance Manager for review. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining dental services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining dental services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining legal services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining legal services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.52(e)(4) LICENSURE Economic support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(4) Economic.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining economic services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining economic services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining educational services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining educational services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |
709.52(e)(6) LICENSURE Vocational Support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(6) Vocational.
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Observations
Based on the review of the facility's referral letters of agreement, the facility failed to document a resource for assisting clients in obtaining vocational services.
The findings include:
On May 14, 2012, the facility's referral letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a primary referral source to assist clients with obtaining vocational services.
An interview with the facility director on May 14, 2012 confirmed the findings.
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Plan of Correction
All referral agreements for Malvern Institute will be updated by June 30, 2012. A database has been created to monitor the completion of all required referral agreements to ensure they are updated every two years. Monthly the Regulatory Compliance Manager will review the facility's referral agreements and the database to ensure all referral agreements are up to date and complete. |