INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on June 2, 2021 through June 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Mirmont Alcohol Rehabilitation Center d/b/a Mirmont Treatment Center 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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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity including the name, address and date of birth prior to the administration of an agent in two of eight applicable patient records reviewed. Patient # 4 was admitted on August 3, 2020 and was discharged on August 5, 2020. There was no documentation that the verification of the patient's identity was completed in the client record prior to the administration of an agent. Patient # 6 was admitted on September 23, 2020 and was discharged on October 2, 2020. There was no documentation that the verification of the patient's identity was completed in the client record prior to the administration of an agent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that the Intake Department staff did not verify the identification of the patients. Intake staff will be trained regarding policy to verify patient identity at July departmental meetings. A compliance report is being developed that returns a list of active patients whose identity was not verified either with an appropriate identification document scanned into the electronic medical record or not verified with an insurance company. The Intake Department Manager is responsible to review the compliance report daily and rectify problems promptly. Intake Department Manager will assure corrective action plan is implemented and will complete chart audits to monitor compliance. Intake Department Manager will report compliance to the Quality Manager. Compliance report scheduled to be implemented 7/15/2021. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in four of eight applicable patient records reviewed. Patient # 2 was admitted on May 29, 2021 and was still active at the time of the inspection. There was no informed, voluntary, written consent documented in the patient record at the time of the inspection. Patient # 4 was admitted on August 3, 2020 and was discharged on August 5, 2020. There was no informed, voluntary, written consent documented in the patient record at the time of the inspection. Patient # 8 was admitted on May 19, 2021 and was still active at the time of the inspection. There was no informed, voluntary, written consent documented in the patient record at the time of the inspection. Patient # 13 was admitted on April 5, 2021 and was discharged on May 6, 2021. There was no informed, voluntary, written consent documented in the patient record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that one psychiatrist failed to obtain the appropriate consent for all four patients in the citation. Although the evaluation was conducted face to face, the consents were either missing patient signature or other required elements of the consent. The psychiatrist will receive education regarding the completion of consent documentation in the electronic medical record. In addition, a daily compliance report will be implemented by July 15,2021. The report will be emailed directly to the psychiatrist and nursing manager and will list active patients with buprenorphine orders that do not have all of the required elements of the consent documented in the electronic medical record (including the patient signature). Incomplete consents will be rectified prior to the administration of an agent. Nursing will complete chart audits to monitor compliance and will report results to Quality Manager. |