INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and for the approval to use a narcotic agent, specifically Buprenorphine in the treatment of narcotic addiction. The inspection was conducted on August 18 - 20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mirmont Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to ensure that staff persons and/or volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as per the regulatory requirements in one of eight records reviewed.
The findings include:
Eight personnel records were reviewed on August 18, 2014 for documentation verifying the completion of the mandatory HIV/AIDS and TB/STD trainings. One out of eight lacked documentation that the trainings was completed as per the regulatory requirements.
Employee # 8, a support staff person, was hired on August 10, 2011. Employee #8 was required to obtain 4 hours of TB/STD training by August 10, 2013. The training was not documented as of the date of the inspection.
The findings were confirmed by facility staff on August 18, 2014.
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Plan of Correction
The staff member who failed to attend the mandatory HIV/AIDS within the mandatory time frame is scheduled to attend the training on Friday, September 19, 2014.
To ensure mandatory training compliance, the Administrative Assistant will maintain a staff spread sheet with the staff's start date; trainings required; and monitor monthly to ensure compliance with trainings. The Administrative Asssitant will inform the department managers of compliance at the quarterly PI meetings. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection, the facility failed to ensure the privacy of the patients in the patient lounge and counselor offices.
The findings include:
The physical plant inspection was conducted on August 19, 2014 at 10:30 am. The facility failed to ensure the privacy of the patients in the new addition of the facility. The patient lounge and counselor offices are facing the parking lot and driveway which leads to the outpatient section of the facility. The facility did not have window coverings on the windows in the patient lounge and counselor offices. This allows anyone coming to the facility viewing access of these areas which results in the patient confidentiality being violated.
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Plan of Correction
To ensure patient privacy in the patient lounge and counsleor offices that face the parking lot, shades will be installed on the windows. The vendor was at Mirmont on September 11, 2014 to take window measurements. Until the shades arrive, 4-6 weeks, opaque plastic will be placed on the windows to act as a privacy barrier, which will allow light into the areas but not allow anyone on the outside to identify anyone inside the building. |