D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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MALVERN INSTITUTE
940 WEST KING ROAD
MALVERN, PA 19355

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Survey conducted on 05/08/2008

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on May 5 through 8, 2008 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 June 9, 2008.	Plan of Correction
709.53(a)(10) LICENSURE Discharge Summary 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: (10) Discharge summary.
Observations Based on a May 5 through 8, 2008 review of client records, the facility failed to document a complete discharge summary in four of four records reviewed, # 7, 8, 9 and 10. Discharge summaries were missing the client's reason for this treatment experience.	Plan of Correction Discharge summaries will be modified so the counselor will discuss this in further detail and will utilize the assessment in the chart where the information is recorded during the dictation. This section of assessment records this information in detail and will be relayed in dictation, giving a summary of client's reason for entering treatment. Clinical Director will monitor this process via closed chart checks.