INITIAL COMMENTS
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This report is a result of findings during and on-site physical plant inspection conducted from May 8-10, 2013, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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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 upon the review of the facility's fire drill log, the facility failed to conduct an unannounced fire drill during one of twelve months reviewed.
The findings include:
The facility's fire drill log for the time frame of June 2012 to May 2013 was reviewed on May 9, 2012. As per documentation contained in the fire drill log, the facility failed to conduct a fire drill during the month of October 2012.
The findings were confirmed by the Director of Administrative and Regulatory Services.
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Plan of Correction
The fire drill that was originally scheduled for October was late and held in November which did not meet standard. In order to ensure fire drills would not be missed in the future, Malvern Institute implemented a new procedure for conducting and tracking fire drillcompletion starting on January 1, 2013. Since January 1, 2013 all fire drills have been conducted every month as scheduled.
Monthly fire drill completion is currently being monitored by the Quality Management office to ensure compliance. Monthly monitoring of fire drill completion will continue on a monthly basis. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain a minimum of two exits that are separated by a minimum distance of 15 feet on every floor.
The findings include:
A physical plant inspection was conducted on May 10, 2013. It was observed during the inspection at approximately 11:00 A.M. that there was only one means of egress from the barn.
The findings were confirmed during an interview with the facility director on May 10, 2013 at approximately 11:05 A.M.
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Plan of Correction
The barn on Malvern Institute's property is an historical landmark and also does not have a seperate certificate of occupancy. Currently the barn is only utilized for storage and patients are not permitted to enter the barn.
Due to the barn being an historical landmark Malvern Institute must obtain township approvals and variances in order to install a secondary exit. Malvern Institute will contact legal counsel to determine the exact township requirements for installation of a secondary exit in the barn. Malvern Institute's legal counsel will then initiate contact with the township to begin the process of obtaining approval to install a secondary exit. |
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 upon the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in four of seven client records.
The findings include:
As per the Director of Administrative and Regulatory Services, the facility does not have a Qualified Service Organization Agreement with a laboratory that they utilize for drug testing.
Seven client records requiring informed and voluntary consent forms were reviewed from May 9-10, 2013. The facility failed to obtain informed and voluntary consent forms for a drug testing laboratory in client records # 7A, 7B, 8A and 9.
Client # 7A was admitted into the detox unit on November 12, 2012, and transferred to the inpatient unit on November 15, 2012. The record contained documentation of disclosures of client information to a drug testing laboratory on November 13 and 14, 2012. However, as of the date of inspection, the record did not contain an informed and voluntary consent from the client for the drug testing laboratory.
Client # 7B was admitted into the inpatient unit on November 15, 2012, and was involuntarily discharged on November 20, 2012. The record contained a discharge summary dated November 21, 2012, that documented the disclosure of client information to two other treatment providers as part of the client's discharge process. However, as of the date of inspection, the record did not contain an informed and voluntary consent from the client for either treatment program.
Client # 8A was admitted into the detox unit on December 27, 2012, and transferred to the inpatient unit on December 31, 2012. The record contained documentation of a disclosure of client information to a drug testing laboratory on December 28, 2012. However, as of the date of inspection, the record did not contain an informed and voluntary consent from the client for the drug testing laboratory.
Client # 9 was admitted on December 21, 2012, and was discharged on January 21, 2013. The record contained documentation of a disclosure of client information to a drug testing laboratory on December 24, 2012. However, as of the date of inspection, the record did not contain an informed and voluntary consent from the client for the drug testing laboratory.
The findings were confirmed by a clinical supervisor during the record review.
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Plan of Correction
As of 4/19/2013 Malvern Institute began obtaining informed consent from all patients upon admission to permit Malvern Institute to disclose infomration to our contracted laboratory. The Director of Admissions has been monitoring the completion of informed consents for our contracted laboratory for all patients who have been admitted since 4/19/2013. Monitoring is completed weekly and will continue to be completed weekly for a period of 3 months.
Staff will be re-educated on the requirement to obtain informed consent from patients prior to releasing information to other treatment providers. This education will be compelted by June 10, 2013 and will be documented. Monitoring of the completiong of informed consents to other treatment providers will be completed weekly by the Evening Supervisor. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based upon the review of client records, the facility failed to demonstrate that it had notified the client in writing of its decision to involuntarily terminate the client's treatment at the project in two of three records.
The findings include:
Three client records of clients whose treatment at the project was involuntarily terminated were reviewed on May 10, 2013. The facility failed to document in client records # 5 and 7B that the clients were informed in writing of the decision to involuntarily terminate their treatment at the project.
Client # 5 was admitted on October 27, 2012, and was involuntarily discharged on November 20, 2012. The facility failed to demonstrate that it had informed the client in writing of the reason for the involuntary termination.
Client # 7B was admitted on October 12, 2012, and was involuntarily discharged on November 20, 2012. The facility failed to demonstrate that it had informed the client in writing of the reason for the involuntary termination.
The findings were confirmed by a clinical supervisor during the record review.
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Plan of Correction
Staff will be re-educated on the requirementt o complete the Malvern Insitute Therapeutic Discharge Form for all patients who are incoluntarily terminated from program. This education will be completed by 6/13/13 and will be documented.
The evening supervisor will monitor completion of the Therapuetic Discharge Form by conducting weekly chart reviews. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based upon the review of client chore assignments and client records, the facility failed to verify that work done by the client at the project was an integral part of his treatment and rehabilitation plan in four of four records.
The findings include:
The facility maintained a dry erase board in the client meeting/dining room that listed chores assigned to clients in the program. The chores listed on the board constituted work therapy assignments as they involved activities above and beyond the cleaning of the client's personal living space.
Four client records requiring verification of work therapy were reviewed on May 10, 2013. The facility failed to verify that the work completed by the clients was an integral part of their treatment plan in client records # 1, 2, 3 and 4.
Client # 1 was admitted on April 15, 2013, and was still an active client on the date of inspection. The record included a treatment plan that was signed by the client on April 19, 2013, that did not include documentation of work therapy. However, as per the client chores listed on the dry erase board, client # 1 was assigned to complete work outside of the cleaning of his personal living space.
Client # 2 was admitted on April 23, 2013, and was still an active client on the date of inspection. The record included a treatment plan that was signed by the client on April 26, 2013, that did not include documentation of work therapy. However, as per the client chores listed on the dry erase board, client # 2 was assigned to complete work outside of the cleaning of his personal living space.
Client # 3 was admitted on April 29, 2013, and was still an active client on the date of inspection. The record included a treatment plan that was signed by the client on April 29, 2013, that did not include documentation of work therapy. However, as per the client chores listed on the dry erase board, client # 3 was assigned to complete work outside of the cleaning of his personal living space.
Client # 4 was admitted on April 13, 2013, and was still an active client on the date of inspection. The record included a treatment plan that was signed by the client on April 18, 2013, that did not include documentation of work therapy. However, as per the client chores listed on the dry erase board, client # 4 was assigned to complete work outside of the cleaning of his personal living space.
A clinical supervisor confirmed the findings during the record review.
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Plan of Correction
Malvern Institute's treatment plan will be revised to include work therapy. All cousnelor will be trained in the completion of the revised treatment plan which includes work therapy. This training will be compelted by 6/13/13 and will be documented.
Clinical Superivsors will monitor the complettion of treatment plans to ensure they include work therapy. Monitoring will be conducted monthly via medical record reviews. |