INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1, 2014 through April 2, 2014 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(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 the Project's Staffing Requirements Facility Summary Reports (SRFSR), the Project failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics training using a Department approved curriculum within the regulatory time frames.
The findings include:
The SRFSR forms completed by the Project (5 total), were reviewed on March 31, 2014. The Project's SRFSR forms listed 2 personnel as not having completed the mandatory training within the regulatory time frames.
Employee # BERW-5 was hired as support staff on November 22, 2004. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than November 22, 2006. The HIV/AIDS training was not documented until July 10, 2013 and the TB/STD and other health related topics training was not documented until October 23, 2013.
Employee # TREV-6 was hired as support staff on March 10, 2010. HIV/AIDS training and TB/STD and other health related topics training were due to be completed no later than March 20, 2012. The HIV/AIDS training was not documented until May 18, 2012 and the TB/STD and other health related topics training was not documented until May 11, 2012.
The Facility Director confirmed the findings during an interview on April 4, 2014.
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Plan of Correction
All new staff hired at any Malvern Institute location will be registered for the TB/STD and HIV trainings within their first 9 months of hire in order to ensure they receive the trainings prior to the due dates. The HR Generalists will be responsible for registering new employees for these trainings and for following up with the employees to ensure they attended. An excel spreadsheet will be maintained to track the completion of these trainings for all new employees. Quarterly the spreadsheet will be reviewed by the Director of Administrative and Compliance Services to ensure continued compliance with the standard. |
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 the Project's Staffing Requirements Facility Summary Reports (SRFSR) and an interview with the Facility Director, the Project failed to ensure that all counselors completed at least 25 clock hours of annual training in one of thirteen personnel records reviewed.
The findings included:
The Project's SRFSR forms (5 total) completed by the Project for the 2014 inspections were reviewed on March 31, 2014. The Project's SRFSR forms listed 1 counselor as not having completed the mandatory 25 clock hours of annual training.
Employee # MALV-6 was hired as a counselor on August 1, 2011. There were only 18 hours of training documented on the SRFSR form for the January 2013 through December 2013 training year.
The Facility Director confirmed the findings during an interview on March 31, 2014.
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Plan of Correction
The employee who failed complete the required number of training hours will receive disciplinary action from his supervisor. This will be documented. A database has been created to monitor the completion of training hours for all counselors and counselor assistants. The HR Generalists will generate monthly reports will from the database indicating each counselor/counselor assistant's current training completion. These reports will be distributed to all Clinical Supervisors. The Clinical Supervisors will then meet with their counselor/counselor assistants monthly to review the employees training completion. These monthly meetings will be documented via the clinical supervision form. 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 Director of Administrative and Compliance Services will meet with the Clinical Supervisors on a quarterly basis to ensure all counselors/counselor assistants are making progress toward their required number of training hours. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential 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 April 2, 2014. It was observed during the inspection at approximately 12:30 P.M. that there was only one means of egress from the barn.
The findings were confirmed during an interview with the Project Director on May 10, 2013. This is a repeat citation from the 05/10/2013 survey.
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Plan of Correction
East Goshen township required that the barn's foundation be stabilized and that the roof be repaired prior to granting approval of installation of a secondary exit. Malvern Institute is currently in the process of stabilizing the barn's foundation and repairing the roof of the barn. Malvern will seek a building permit from East Goshen Township by July 1 for the installation of the second fire exit. Once we have secured the building permit, we will initiate construction of the second exit, which should take no longer than one month. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document complete physical examinations in five of eleven client records reviewed.
The findings include:
Eleven client records requiring the complete documentation of physical examinations were reviewed on 04/01/2014 - 04/02/2014. The facility failed to document all the required elements of the physical examinations as part of the intake process in client records # 1, 4, 6, 9, and 11.
Client # 1 was admitted on 03/02/2014 and was discharged on 04/01/2014. The physical examination was completed on 03/03/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 4 was admitted on 08/21/2014 and was discharged on 09/07/2014. The physical examination was completed on 08/22/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 6 was admitted on 03/05/2014 and was and was still an active client as of the date of the on-site inspection. The physical examination was completed on 03/06/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 9 was admitted on 02/26/2014 and was discharged on 03/27/2014. The physical examination was completed on 02/27/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 11 was admitted on 01/15/2014 and was discharged on 01/26/2014. The physical examination was completed on 01/16/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
The Project Director confirmed the findings.
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Plan of Correction
All physicians will be re-educated on the requirement to complete patient vital signs during the physical examination. This education will be documented.
The Assistant Director of Nursing will monitor the completion of the vitals on the physical examinations through monthly medical records reviews. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document complete physical examinations in five of eleven client records reviewed.
The findings include:
Eleven client records requiring the complete documentation of physical examinations were reviewed on 04/01/2014 - 04/02/2014. The facility failed to document all the required elements of the physical examinations as part of the intake process in client records # 1, 4, 6, 9, and 11.
Client # 1 was admitted on 03/02/2014 and was discharged on 04/01/2014. The physical examination was completed on 03/03/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 4 was admitted on 08/21/2014 and was discharged on 09/07/2014. The physical examination was completed on 08/22/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 6 was admitted on 03/05/2014 and was and was still an active client as of the date of the on-site inspection. The physical examination was completed on 03/06/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 9 was admitted on 02/26/2014 and was discharged on 03/27/2014. The physical examination was completed on 02/27/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
Client # 11 was admitted on 01/15/2014 and was discharged on 01/26/2014. The physical examination was completed on 01/16/2014; however there was no inclusion of vital signs on the physical examination documentation in the client record as of the date of this inspection.
The Project Director confirmed the findings.
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Plan of Correction
All physicians will be re-educated on the requirement to complete patient vital signs during the physical examination. This education will be documented. The Assistant Director of Nursing will monitor the completion of the vitals on the physical examinations through monthly medical records reviews.
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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 the review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in eight of ten client records.
The findings include:
Eleven client records were reviewed on April 1, 2014 - April 2, 2014. Individual treatment and rehabilitation plans, including proposed type of support services, were required in ten records. The facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in client records #1, 2, 4, 5, 6, 7, 9, and 10.
Client #1 was admitted on 03/02/2014 and was discharged on 04/01/2014. A treatment and rehabilitation plan was completed on 03/13/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
Client #2 was admitted on 03/08/2014 and was still an active client as of the date of the on-site inspection. A treatment and rehabilitation plan was completed on 03/10/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
Client #4 was admitted on 08/21/2014 and was discharged on 09/07/2014. A treatment and rehabilitation plan was completed on 08/29/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
Client #5 was admitted on 12/12/2013 and was discharged on 01/10/2014. A treatment and rehabilitation plan was completed on 12/16/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
Client #6 was admitted on 03/05/2014 and was still an active client as of the date of the on-site inspection. A treatment and rehabilitation plan was completed on 03/10/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
Client #7 was admitted on 03/07/2014 and was discharged on 04/01/2014. A treatment and rehabilitation plan was completed on 03/12/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
Client #9 was admitted on 02/26/2014 and was discharged on 03/27/2014. A treatment and rehabilitation plan was completed on 03/03/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
Client #10 was admitted on 02/24/2014 and was discharged on 03/24/2014. A treatment and rehabilitation plan was completed on 03/10/2014. The facility failed to include the proposed type of support services on the treatment and rehabilitation plan.
The Project Director confirmed the findings.
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Plan of Correction
All counseling staff will participate in a training on the definition of 'support services' and the inclusion of support services on the treatment plan. this training will be conducted by the Clinical Supervisors and will be documented.
All active patient records cited will have their treatment plans revised by their counselors to include supportive services. These treatment plan revisions will be completed by May 16th.
The Clinical Supervisors will complete monthly medical records reviews to ensure support services are included in treatment plans. Any deficiencies identified will be discussed in regular supervision with counseling staff.
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