INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16 through 18, 2011 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records and conversation with the project director, it was confirmed that the facility failed to demonstrate that performance evaluations were conducted semi-annually for counselor assistants.
The findings were:
Seventeen employee records were reviewed on May 16, 2011. Four records were counselor assistants. One record was employed for over a year and required semi-annual performance evaluations. Employee record #11 was hired May 21, 2009. There was one performance evaluation documented in the employee record on May 21,2 010. The facility failed to document semi-annual performance evaluation for the counselor assistant. A conversation with the acting project director on May 16, 2011 confirmed that only one performance evaluation was conducted for Employee #11.
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Plan of Correction
Semi-annual reviews will be conducted for all counselor assistants going forward. This will be completed by the Clinical Supervisor. This will be tracked and monitored by the Executive Director. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records and an interview with the project director, the facility failed to ensure that a counselor assistant documented to the facility director that he is working toward counselor status.
The findings include:
Seventeen personnel records were reviewed on May 16, 2011. Counselor Assistant documentation of working toward counselor status was required in one personnel record. The counselor assistant did not document to the facility director that he is working toward counselor status in personnel record # 11. An interview with the project director on May 16, 2011 at 2:30 p.m. confirmed that the counselor assistant did not document to the facility director what he was doing to work toward counselor status.
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Plan of Correction
Said counselor assistant has confirmed via email that he plans to obtain his CAC and is investigating courses at a local university. All other counselor assistants will be asked to confirm their educational goals to ensure movement towards counselor position. This will be monitored by the Exeuctive Director.
Educational goals of Counselor Assistants will be submitted in writing to the Executive director by December 1st of each year. This date coincides with their annual review, which is conducted in the month of January.
All Counselor Assistants will be made aware of this policy in writing by July 1, 2011. |
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 a physical plant inspection and an interview with the project director, 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 residents, employees and visitors.
The findings include:
A physical plant inspection took place on May 17, 2011. During the inspection a television approximately 52 inches wide was sitting on two milk crates on the top of a table. The television was not secure and could easily cause a hazard to the residents, employees and visitors as it could easily slide off or fall from these crates.
An interview with the project director took place on May 18, 2011 and confirmed this observation.
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Plan of Correction
The TV will be placed on a new stand by June 17. Maintenance Supervisor has been notified via email to have this complete. This will be monitored by the Exec Dir |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on the physical plant inspection, the facility failed to ensure that there were individual paper towels or a mechanical dryer in each bathroom along with an operable soap dispenser.
The findings include:
The physical plant inspection was conducted on May 17, 2011. During the inspection it was observed that the facility failed to have either individual paper towels or a mechanical dryer and soap in the bathroom attached to the client room # 4.
The project director confirmed this observation.
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Plan of Correction
All bathrooms will have mechanical dryers and soap dispensers. Maintenace Director was notified via email. To be complete by June 30. This will be monitored by Executive Director |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 F.
The findings include:
The physical plant inspection took place on May 17, 2011. The water temperature was taken in the bathroom attached to Room # 6 at 12:00 p.m. The hot water temperature exceed 120 F. The water temperature was 150 F.
The project director was interviewed and confirmed this observation.
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Plan of Correction
Water heater was adjusted to 118 degrees Farenheit on May 18, 2011.
Maintenace manager was informed of this requirement on May 18, 2011.
Going foward, Maintenance Manager will check water temp monthly to ensure that the appropriate temperature is maintained. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on the physical plant inspection the facility failed to store the utensils in a clean enclosed area.
The findings include:
The physical plant took place on May 17, 2011. It was observed at 3:30 p.m. that the eating utensils were on a rack in separate containers but were not covered. This was again observed on May 17, 2011 at 9:00 a.m.
An interview with the project director at 9:20 a.m. on May 18, 2011 confirmed this finding.
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Plan of Correction
Director of Dietary is ordering covers for the utensils. They will be on by June 30. The Exec Dir will ensure this. Dietary manager knows to check to ensure silverware covers are in place on a daily basis. This process will be monitored by Exec Dir |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on the review of client medical records, the facility policy and procedure manual, and staff and client interviews it was documented the facility failed to be free of rodent and insect infestation. Additionally, the facility failed to have a policy and procedure in place to help prevent the infestation of bed bugs.
The findings include:
The facility policy and procedure manual was reviewed on May 16 and 17, 2011. The physical plant inspection took place on Tuesday May 17, 2011. During the physical plant inspection it was observed that all new linens were issued that day for the client beds.. Interviews took place with clients to determine what the normal day for linen exchange was and it was noted as Thursday. No evidence was observed in patient bedrooms that indicated bed bugs. However, a staff interview with the nurse on duty in the medication station stated that bed bug bites were reported on May 16, 2011 by a patient. The nursing notes and doctors notes for this patient were reviewed and it indicated that the patient had bed bug bites. Staff interviews with the project director and nursing staff were conducted at 2:50 p.m. The staff indicated that the facility did not have a policy and practice in place for clients entering the facility to help prevent the infestation of bed bugs.
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Plan of Correction
Follow up extermination was complete on June 7 - no evidence of any bed bugs was found. Policy will be updated to prevent re-occurance. Extermination will occur monthly for the next 6 months to ensure there is no re-occurance. If a pt reports bed bugs, linens will be dried, clothes will be dried and pt will be moved to a new room. Also, all the wooden bed frames will be replaced by metal frames. The new bed frames will be set up by June 30. Precautionary procedures to be implemented on a daily routing admission are:
1) Patients are being limited to one clothing bag when admitted to facility. 2) Bags will be inspected and if considered questionable, will be washed and dryed prior to being given to the patient for use in the facility. 3)rooms are cleaned, vacuumed and sanitized every time a patient is assigned to the room. 4) New linens and bedding are dispensed every time a patient is assigned to a room. This process will be monitored by Exec Dir |
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 the physical plant inspection the facility failed to light interior exit and stairs at all times.
The findings include:
The physical plant inspection took place on May 17, 2011. At approximately 2:30 p.m. it was observed that the light in the stairwell leading from the second to the third floor was not on. The licensing specialist and the project director tried to turn the light on, but it would not work. The facility did correct this deficiency during the licensing visit.
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Plan of Correction
The light has been working and is checked on daily by Maintenance Supervisor to ensure that it continues to work. If the lights should go out again, it will be fixed immediately. Exec Dir will monitor this. |
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 review of the administrative documentation and an interview with the project director, the facility failed to make the 2009/2010 annual report available to the public.
The findings include:
The 2009/2010 annual report was reviewed on May 17, 2011. The facility failed to document that the annual report was made available to the public. An interview with the project director on May 17, 2011 at 9:00 a.m. confirmed that the annual report for fiscal year July 1, 2009 through June 30, 2010 had not been made available to the public.
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Plan of Correction
A statement that the 2009-2010 annual report and consequent annual reports is available to the public and a link to contact information for the purpose of obtaining a copy will be posted on the company website by July 11,2011. Responsible party will be Project director. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative policies and Board meeting minutes the project failed to demonstrate that the project director assisted the governing body in formulating project goals and objectives for the 2010/2011 fiscal year.
The findings were:
A review of board meeting minutes indicated that the board failed to document that they approved the 2010/2011 goals and objectives. A conversation with the project director on May 16, 2011 at 2:30 p.m. confirmed that the governing body did not approve the goals and objectives for the 2010/2011 fiscal year.
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Plan of Correction
Goals and objectives are presently complete for the fiscal year ending June 30 2011. Goals and objectives will be presented to the board on July 8,2011 for board approval. Exec Dir will attend meeting and ensure this is complete. A reminder system will be used going forward and will be monitored by Exec Dir |
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) in 8 of 14 client records.
The findings include:
Based on the review of records on May 17-18, 2011, the facility failed to ensure that the information disclosed to the funding source did not exceed 4 Pa Code Subsection 255.5 (b). In client records #3, 4, 6, 7, 8, 9, 10, 11, and 14, release forms for funding sources documented that the face sheet could be released to the insurance company. The face sheet contained the following information that exceeded 255.5 (b); treatment history, emergency contact, medical history, medication, psychiatric history, living situation and legal information.
This is a repeat citation from the licensing visit conducted on May 3-4, 2010 and an unannounced follow-up inspection on November 16, 2010.
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Plan of Correction
Executive Director will remove "face sheet" from all consents to ensure proper following of confidentiality laws. All staff will be advised of thsi change and be educated on confidentiality by the Exec Dir via training. This will occur by June 30. Compliance going forward will be monitored by Exec Dir |