INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2022 through June 24, 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 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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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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of fourteen client records reviewed.Client # 4 was admitted to the inpatient non-hospital detoxification activity on May 17, 2022 and was discharged on May 22, 2022. There was a release of information form to the funding source, signed and dated by the client and witness on May 17, 2022. The expiration date listed on the form was May 17, 2022. There was evidence of disclosures to the funding source during the client's treatment episode after the expiration date; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.Client # 4 was admitted to the inpatient non-hospital activity on May 23, 2022 and was still active at the time of the inspection. There was a release of information form to the funding source, signed and dated by the client and witness on May 17, 2022. The expiration date listed on the form was May 17, 2022. There was evidence of disclosures to the funding source during the client's treatment episode after the expiration date; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identification of Failure: Admissions staff obtained a ROI for Client #4, but placed the wrong date for the expiration of the ROI form. They entered the expiration date the same as the effective date on the form.
Action: The Admission and Clinical staff were re-educated on the importance of making sure the consent to release information forms are completed correctly with the appropriate effective date and expiration date.
Client #4 discharged 6/30/2022 and cannot be updated.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with entering the correct effective and expiration dates on the consent to release information forms. 25 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 one applicable client record reviewed.Client # 12 was admitted to the inpatient non-hospital activity on March 18, 2022 and was administratively discharged on April 10, 2022. There was no documentation in the record indicating 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 counselor attempted to work with the patient during the involuntary discharge process but the patient refused all interventions and assistance, wanting to leave immediately. The counselor did not complete the Involuntary Discharge Note in the EMR.
Action: The clinical staff were re-educated on the requirement to complete the Involuntary Discharge Note in the EMR which prompts the clinical staff to provide a copy of the note with the reason for the decision to involuntarily terminate the client's treatment at the project.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with the requirement to complete the Involuntary Discharge Note which prompts the clinical staff to provide a copy of the note with the reason for the decision to involuntarily terminate the client's treatment at the project. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
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 one applicable client record reviewed.Client # 12 was admitted to the inpatient non-hospital activity on March 18, 2022 and was administratively discharged on April 10, 2022. There was no documentation in the record indicating 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: The electronic medical record did not have a notification that the client has an opportunity to request reconsideration of the facility's decision to terminate treatment.
Action: The electronic medical record termination form has been edited to require the question regarding appeal to be answered before the document can be saved and completed.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance regarding the patient having the opportunity to request reconsideration of a decision terminating treatment. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |
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 # 11 was admitted to the inpatient non-hospital activity on February 21, 2022 and was discharged on March 7, 2022. The client record did not document a discharge summary at the time of the inspection.Client # 12 was admitted to the inpatient non-hospital activity on March 18, 2022 and was discharged on April 10, 2022. The client record did not document a discharge summary at the time 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 counselors for Client #11 and Client #12 failed to complete the discharge summary as required.
Action: The clinical staff were re-educated on the 709.53 (a)(10) requirement to complete the discharge summary.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with completing the discharge summary. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |