INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on February 26, 2007 through March 1, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on March 28, 2007.
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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
The written procedures on timeframes for the completion of client record documentation contained conflicting procedures in the program's manuals.
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Plan of Correction
The policy and procedure for the completion of client record documentation was not updated to reflect current practice. The project director will revise the policy and procedure to ensure consistancy in the written policies. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The annual audit was not completed within six months of the end of the project's fiscal year.
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Plan of Correction
The annual audit was not completed within six months of the end of the fiscal year because the auditing firm PriceWaterhouseCoopers did not complete the audit in a timely way. The project director and finacial director have made their displeasure known to the auditors. PWC ensured Mirmont executives that the audit will be done in a timely fashion for Fiscal Year 2006/07. |
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
Parent/guardian signature lines were included on the consent for voluntary inpatient treatment forms, consent to treatment forms, patient rights forms and the patient confidentiality and disclosure of criteria forms in 25 of 25 client records reviewed. Parental consent for disclosure of information is not mandated by state law and cannot be required.
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Plan of Correction
Old consent and other forms from the adolescent program were mistakenly being used in the adult admissions packet. Director of quality management will discard(recycle)the old forms and replace with revised versions that will not have the parent/signature line on them. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
The consent to release information forms did not include the purpose of disclosure in 13 of 25 client records reviewed, #3, 4, 5, 7, 8, 9, 10, 11, 14, 16, 20, 21 and 24.
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Plan of Correction
Forms were not being filled out properly. Director of Admissions will hold an inservice for the admissions staff to review the policy and procedure for proper completion of the consent to release information. Director of Admissions will monitor to ensure compliance. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
The consent to release information forms did not include whether or not the client had been offered a copy of the signed consent form in 8 of 25 client records reviewed, #1, 6, 8, 10, 14, 20, 21 and 24.
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Plan of Correction
Forms were not being completed thoroughly. The Director of Admissions will complete an inservice with staff to review the policy and procedure for proper completion or the consent to release information. Director of Admissions will monitor to ensure compliance. |
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
The notice of termination did not include a statement informing clients of their right to request reconsideration in two of two client records reviewed, #16 and 18.
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Plan of Correction
Right to request reconsideration was always given verbally, but was not written into the policy and procedure. Clinical Director will revise policy and procedure for involuntary discharges to include a right to request reconsideration and the notice of termination will also be revised to include a statement informing clients of their right to request reconsideration. Clinical director, nursing director and clinical aide coordinator will review with their staffs at their staff meetings. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
During the past 12 months, only one fire drill was conducted during sleeping hours.
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Plan of Correction
Mirmont conducts fire drills on a regular basis on all three shifts. The fire drill in question was conducted on third shift( 12 Midnight to 8:30 AM) after the patients were awake. The Director of Facilities will conduct a minimum of two fire drills in the coming year during sleeping hours. The Director of Facilities will monitor the fire drills to ensure compliance. |
709.63(a)(6) LICENSURE Aftercare plan
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:
(6) Aftercare plans, if applicable.
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Observations
The aftercare plan lacked specific, measurable goals and support services in one of one client record reviewed, #15.
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Plan of Correction
The Clinical Supervisor will meet with the counselor who did not include specific measurable goals and support services in the one client record reviewed, to review the standard, and discuss appropriate aftercare planning. The clinical supervisor will monitor aftercare plans for compliance . |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol histories included discrepancies with regards to substances abused in four of nine client records reviewed, #6, 14, 19 and 20. The lengths/patterns of use was missing in eight of nine client records reviewed, #6, 7, 8, 9, 10, 14, 19 and 20.
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Plan of Correction
THe drug and alcohol histories were not properly filled out in several client records. THe clinical supervisor, director of nursing and the director of admissions will all hold inservices with their staffs to review the proper way to complete a drug and alcohol history. Special emphasis will be place on completing the lenjgths and patterns of use. All three managers will monitor client records for compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing information regarding the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit Traitement and clinical impressions in four of nine client records reviewed, #6, 10, 14 and 19.
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Plan of Correction
The clinical director will hold an inservice for the counselors and review the proper way to complete the bio-psycho-social assessment and evaluation. Clinical Directror will emphasize client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and clinical impressions. Clinical supervisor will monitor client records for compliance. |
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
Support services were missing in seven of seven client records reviewed, #6, 7, 8, 9, 14, 19 and 20.
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Plan of Correction
Counselors failed to document support services in the client's record. Clinical Director will hold an inservice to review the importance of documenting support services in the client record. Clinical Director will monitor client records for compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates were missing in two of three client records reviewed, #14 and 20.
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Plan of Correction
Clinical Supoervisor will hold an inservice with the counselsors to review standards and policies and procedures regarding treatment plan updates. Clinical supervisor will then monitor for timely completion of treatment plan updates. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Individual therapy sessions were not documented for several weeks (as identified on the treatment plan) in two of seven client records reviewed, #6 and 14.
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Plan of Correction
Individual counseling sessions were not documented. Clinical supervisor will hold an inservice with the counselors to review Mirmont's documentation guidelines. Clinical director will ensure compliance with the standard and monitor for ongoing compliance. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in three of nine client records reviewed, #7, 14 and 20. Case consultation summaries and dispositions were disjointed in six of nine client records reviewed, #6, 8, 9, 10, 11 and 19.
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Plan of Correction
Clinical supervisor will hold an inservice for counselors to review the policy and procedure and the DDAP standard for case consultation. The clinical supervisor will monitor client records for compliance |
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
Discharge summaries were missing in one of three client records reviewed, #14.
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Plan of Correction
A discharge summary was missing. The clinical supervisor will hold an individual supervisory session with the counselor who failed to include the discharge sunmmary in the client record, review the policy and procedure for timely completion of summaries with the counselor and then monitor for ongoing compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
The drug and alcohol histories included discrepancies with regards to substances abused in two of 12 client records reviewed, #1 and 4. The lengths and patterns of use contained limited information in eight of 12 client records reviewed, #1, 4, 5, 7, 8, 9, 23 and 24.
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Plan of Correction
Inconsistent histories. The clinical supervisor will hold an inservice with the counselors to review the policy and procedure for consistent and proper completion of drug and alcohol histories. the Clinical supervisor will monitor client records for compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal histories contained limited information regarding family and employment histories in four of 12 client records reviewed, #1, 4, 5 and 7. The personal history was late in one of 12 client records reviewed, #4. The personal history was not updated from a previous treatment episode in one of 12 client records reviewed, #5.
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Plan of Correction
Personal hisories were inconsistent and lacking information. The clinical supervisor will hold an inservice to review the policy and procedure for the proper and consistent completion of the personal histories. The clinical supervisor will monitor the client records for compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing in two of eight client records reviewed, #5 and 23 and late in one of eight client records reviewed, #4. Psychosocial evaluations were more historical than evaluative in three of eight client records reviewed, #1, 2 and 4.
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Plan of Correction
The clinical supervisor will hold an inservice for the counselors to review the policy and procedure to the timely, proper and consistent completion of the psychosocial evaluations. The clinical supervisor will monitor the client records for compliance. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
The treatment plan action steps did not contain measurable action steps in four of eight client records reviewed, #2, 4, 5 and 21. The treatment plan was completed late in two of eight client records reviewed, #1 and 21.
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Plan of Correction
The clinical supervisor will hold an inservice with the counselors to review the standars and the policy and procedures for the timely, proper and consistent completion of treatment plans. the clinical supervisor will monitor for compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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
Support services were missing in three of eight client records reviewed, #1, 4 and 23.
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Plan of Correction
Clinical supervisor will hold an inservice to review the importance of documenting the inclusion of support services in the client record. The clinical supervisor will monitor the client records to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Treatment plan updates were missing in two of six client records reviewed, #23 and 24. Treatment plan updated were late in three of six client records reviewed, #2, 3 and 5. Treatment plan updates did not reflect progress on previous treatment plan goals in three of six client records reviewed, #2, 3 and 5.
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Plan of Correction
Clinical supervisor will hold an inservice with the counselors to review the standards and the policy and procedures for timely and proper completion of treatment plan updates. Clinical supervisor will monitor the client records to ensure compliance. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in two of six client records reviewed, #2 and 23.
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Plan of Correction
The clinical supervisor will meet with the counselor(s) who did not include case consultations in the client records to review the standard and the policy and procedure for case consultation. The clinical supervisor will monitor to ensure compliance. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Aftercare plans were missing in two of four client records reviewed, #5 and 23. Aftercare goals were solely completed by the client without being reviewed by the counselor in two of four client records reviewed, #24 and 25. The aftercare plan was missing support services in two of four client records reviewed, #24 and 25.
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Plan of Correction
The clinical supervisor will conduct and inservice for the counselors to review the standards and the policy and procedures for the timely and proper compltion of aftercare plans. The clinical supevisor will monitor to ensure on-going compliance. |
709.93(a)(10) LICENSURE Client records
709.93. 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
Discharge summaries were missing in two of two client records reviewed, #1 and 23.
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Plan of Correction
Clinical director will meet with counelors to conduct an inservice on timely completion of discharge summaries and the insertion of the summaries into the client record. The clinical supervisor will monitor to ensure compliance. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
One counselor did not meet the qualifications due to an expired CAC, #7.
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Plan of Correction
The director of Human Resources has received the counselor's recertification certificate from the state of Delaware. The counselor is appling for reciprocity in the state of PA to receive her CAC. The Director of Human Resources will monitor all counselor's credentials to insure compliance with state standards. |