INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection monitoring conducted on June 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection Malvern Treatment Centers 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.Client # 11 was admitted to the inpatient non-hospital activity on February 20, 2022 and was discharged against medical advice on February 26, 2022; however, the emergency contact was not notified until February 28, 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The Clinician/Clinical Supervisor failed to document the contacting of the client's emergency contact within 12 hours of the client leaving treatment against medical advice.
Action: All clinicians were re-educated that the emergency contact must be notified within 12 hours of a client leaving treatment against medical advice, and that the notification must be documented in the client's chart.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance with documenting contact with the emergency contact within 12 hours of a client leaving the facility against medical advice. 15 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in one of fourteen client records reviewed. Client # 11 was admitted to the inpatient non-hospital activity on February 20, 2022 and was discharged on February 26, 2022. There was a release of information form to a government agency, signed and dated by the client and witness on February 23, 2022, that allowed for the release of the entire record, which exceeded the limits established by 4 Pa. Code 255.5. This is a repeat citation from the November 4, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: The release of information signed by client and witness allowed for the entire record. The release for Client #11 exceeded the limit of disclosure established by 4 PA code 255.5.
Action: While no records were released to the government facility, the facility recognizes the broad scope of the release and the staff will be re-educated on the information able to be released as outlined in code 255.5.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding the information able to be released as identified in code 255.5. 15 charts will be audited each month with a goal of 100% compliance for 3 months. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of fourteen client records reviewed. Client # 12 was admitted to the inpatient non-hospital activity on February 18, 2022 and was discharged on March 8, 2022. The release of information form to another treatment provider was signed and dated by the witness on March 9, 2022, but the form did not document the dated signature of the client. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: The release of information reflected two clinician signature as documentation of a verbal consent from the client. The release of information for another treatment provider regarding Client #12 failed to be signed and dated by the client prior to discharge.
Action: Clinicians have been re-educated on obtaining client signatures on releases prior to the client's discharge.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding client signatures for all releases prior to discharge. 15 charts will be audited each month with a goal of 100% compliance for 3 months. |
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 on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of two applicable client records reviewed.Client # 12 was admitted to the inpatient non-hospital activity on February 18, 2022 and was administratively discharged on March 8, 2022. There was no documentation in the record that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The Clinician/Clinical Supervisor failed to notify the client, in writing, of the facility's decision and reason for the involuntary termination of the client's treatment.
Action: The clinical staff have been re-educated on the completion of written notification, which is to include the reason for the facility's decision to involuntarily terminate the client's treatment.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding the written documentation of the client being notified of the facility's decision and reasoning to terminate treatment. 15 charts will be audited each month with a goal of 100% compliance for 3 months.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of two applicable client records reviewed.Client # 12 was admitted to the inpatient non-hospital activity on February 18, 2022 and was administratively discharged on March 8, 2022. There was no documentation in the record that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Malvern Treatment Centers' Discharge Planning Policy states that staff is to notify the client of their rights of involuntary termination and allow the client the right to request reconsideration of the facility's decision to terminate treatment.
Action: Clinical staff was re-educated on the Discharge Planning Policy regarding the client's rights to appeal the facility's decision for termination and clinical documentation of the client having been made aware of their right to appeal. Staff was re-educated to complete this documentation prior to discharge.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance regarding the documentation of clients having the opportunity to request reconsideration of the facility's decision to terminate treatment. 15 charts will be audited each month with a goal of 100% compliance for 3 months.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's December 2021 through May 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident at the facility of a physical assault involving clients on March 8, 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The Risk Manager failed to submit an unusual incident report with the Department of a physical assault.
Action: The Risk Manager was re-educated on the standard of reporting unusual incidents and submission process within 3 business days following an unusual event. The Risk Manager will file all unusual incident reports with the Department within 3 business days of the unusual event.
Monitoring: The submission of unusual incident reports will be completed with 100% compliance as outlined in standard § 709.34; reporting of unusual incidents. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's December 2021 through May 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.Police and/or ambulance personnel incidents occurred on the following dates, that were not reported to the Department: December 8, 2021; December 18, 2021; December 26, 2021; January 1, 2022; January 8, 2022; January 10, 2022; January 16, 2022; January 21, 2022; February 14, 2022; February 21, 2022; February 25, 2022; March 29, 2022; March 30, 2022; March 31, 2022; April 12, 2022, April 18, 2022 and April 25, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The Department failed to receive unusual incident reports within 3 business days following the event days. However through user error or system error, the facility was unaware of the reports not being received by the Department.
Action: The Risk Manager was re-educated on the standard of reporting unusual incidents and submission process within 3 business days following an unusual event. A test submission was completed along with the facility obtaining verification of the Department receiving the submission. The Risk Manager will file all unusual incident reports with the Department within 3 business days of the unusual event.
Monitoring: The submission of unusual incident reports will be completed with 100% compliance as outlined in standard § 709.34; reporting of unusual incidents. |
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.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a discharge summary, in two of four applicable records reviewed.Client # 12 was admitted to the inpatient non-hospital activity on February 18, 2022 and was discharged on March 8, 2022. The client record did not document a discharge summary as of the date of the inspection.Client # 14 was admitted to the inpatient non-hospital activity on January 27, 2022 and was discharged on February 16, 2022. The client record did not document a discharge summary as of the date of the inspection.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Identification of Failure: The clinician for Client #12 and Client #14 failed to document the discharge summary in the client's record.
Action: All clinicians have been re-educated on the completion of discharge summaries within 7 days of a client's discharge.
Monitoring: Monitoring will be completed monthly by the Clinical Director/designated staff and monitored by the Risk Manager during monthly audits to establish compliance with the documenting of discharge summaries within 7 days of the client's discharge. 15 charts will be audited each month with a goal of 100% compliance for 3 months. |