INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 9, 2009 through June 11, 2009 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 and a plan of correction is due on July 10, 2009.
|
Plan of Correction
|
705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
|
Observations
Based on a physical plant inspection on June 11, 2009, the facility failed to ensure each bedroom was ventilated by operable windows.
The findings include:
A physical plant inspection was conducted on June 11, 2009 at approximately 11:30AM. During the inspection, approximately half of the windows in the client bedrooms were broken and unable to be opened for ventilation.
|
Plan of Correction
The windows will be repaired or replaced by a company specializing in windows. This will be monitored by the Executive Director. This will be completed by July 15. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
|
Observations
Based on a physical plant inspection on June 11, 2009, the facility failed to ensure that there were slip-resistant surfaces in all bathtubs and showers.
The findings include:
A physical plant inspection was conducted on June 11, 2009 at approximately 11:30AM. During the inspection there were no slip-resistant surfaces in any of the showers.
|
Plan of Correction
A wrok order has been submitted to have Slip-Resistant bath mats/stickers placed on each shower and bath by Executive Director. Work order was submitted June 25 and will be completed by June 26. Executive Director will monitor process. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records on June 11, 2009, the facility failed to document a psychosocial evaluation that included an overall composite picture of the client, a thorough identification of the client's problems/needs, strengths and coping mechanisms in ten of twelve client records.
The findings include:
Twelve client records were reviewed on June 11, 2009. A psychosocial evaluation was required in eleven client records. The facility did not document a composite picture of the client in client records #3, 4, 5, 7, 8, 9, 10 and 11. The facility did not completely identify the client's problems/needs in client records #3, 4, 8 and 11; the client's problems/needs were identified as addiction, but did not identify individualized issues, such as grief, depression, etc. The facility did not identify the client's coping mechanisms in client records #1, 4, 6, 7, 8 and 9. Coping mechanisms were identified as drug and/or alcohol use or as "none."
|
Plan of Correction
Each counselor will be educated and trained on completing psychosocial evaluations correctly via in-service using example evaluations by this writer. Counselors will be educated on composite picture, strengths/needs and coping mechanisms. This will occur by June 30. This will be monitored via chart checks by the Clinical Supervisor under direction of Executive Director. Prior to June 30, each counselor's psychosocial evaluation will be reviewed by this writer or Clinical Supervisor and approved prior to being filed in patient record. |
709.63(a)(3) LICENSURE Progress notes
709.63. 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:
(3) Progress notes.
|
Observations
Based on the review of client records on June 11, 2009, the facility failed to document progress notes to include data, assessment and plans relative to treatment in six of twelve client records.
The findings include:
Twelve client records were reviewed on June 11, 2009. Progress notes were required in eleven client records. The facility did not document individual progress notes with an assessment section in client records #8, 9, 10 and 11. The information contained in the assessment section was data rather than an assessment of the client. The facility did not document group progress notes with an assessment of the client in client records #2, 7, 8, 9, 10 and 11. The group notes utilized a pre-printed check off format that did not clearly assess the client.
|
Plan of Correction
Counselors will include information that is appropriate to "Data" section rather placing in "Assessment" section. Counselors will be educated on this process via in-service using examples to demonstrate "Data" "Assessment" and "Plan". This will be conducted by Executive Director. This will be monitored by daily chart checks by Clinical Supervisor under direction of Executive Director. This will occur by July 15. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records on June 11, 2009, the facility failed to document a psychosocial evaluation that included an overall composite picture of the client, a thorough identification of the client's problems/needs, strengths and coping mechanisms in ten of twelve client records.
The findings include:
Twelve client records were reviewed on June 11, 2009. A psychosocial evaluation was required in eleven client records. The facility did not document a composite picture of the client in client records #3, 4, 5, 7, 8, 9, 10 and 11. The facility did not thoroughly identify the client's problems/needs in client records #3, 4, 8 and 11. The client's problems/needs were identified as addiction, but did not identify individualized issues, such as grief, depression, etc. The facility did not identify the client's coping mechanisms in client records #1, 4, 6, 7, 8 and 9. Coping mechanisms were identified as drug and/or alcohol use or as "none."
|
Plan of Correction
Each counselor will be educated and trainied on completing psychosocial evaluations correcly via in-service using example evaluations by this writer. Counselors will be educated on compostite picture, strengths/needs and coping mechanisms. This will occur by July 15. This will be monitored by the Clinical Supervisor via chart checks under direction of Executive Director. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
|
Observations
Based on the review of client records on June 11, 2009, the facility failed to document individualized treatment and rehabilitation plans in five of nine client records.
The findings include:
Twelve client records were reviewed on June 11, 2009. Individualized treatment plans were required in nine client records. The facility did not document treatment plans individualized to each client's needs in client records #1, 2, 4, 8 and 10. The treatment plans failed to include issues that were identified in patient assessment and evaluations.
|
Plan of Correction
Counselors will be educated on importance of individualizing treatment plans based on assessment via inservice by this writer. This will be monitored by Clinical Supervisor under direction of Executive Director. This writer will utilize sample treatment plans as part of in-service. This will be occur by July 15. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
|
Observations
Based on the review of client records on June 11, 2009, the facility failed to document progress notes to include data, assessment and plans relative to treatment in six of twelve client records.
The findings include:
Twelve client records were reviewed on June 11, 2009. Progress notes were required in eleven client records. The facility did not document individual progress notes with an assessment section in client records #8, 9, 10 and 11. The information contained in the assessment section was data rather than an assessment of the client. The facility did not document group progress notes with an assessment of the client in client records #2, 7, 8, 9, 10 and 11. The group notes utilized a pre-printed check off format that did not completely assess the client.
|
Plan of Correction
Counselors will be educated via inservice by this writer on including Data information in Data section rather Assessment section. This will be monitored by Clinical Supervisor via chart checks under direction of Executive Director. Inservice will occur by July 15. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of CPR and first aid certification cards and staff interview, the facility failed to provide a sufficient number of staff persons with CPR and first aid training.
The findings include:
The sole transportation driver documented by the facility did not have CPR and first aid training. This does not provide adequate CPR and first aid coverage during the offsite transportation of clients.
|
Plan of Correction
A second driver who is CPR certified was hired to drive in place of current driver until current driver is CPR certified. Second driver CPR exp date is May 2010. Current driver will be CPR certified by June 30. This will be monitored by Executive Director. |