INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from August 31, 2015 through September 2, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of the personnel and training records, the facility failed to document that a core curriculum in clinical supervision was completed in three of three personnel records.
The findings include:
Fourteen personnel records were reviewed on August 31, 2015. Three records were required to have clinical supervision core curriculum training documented. The facility failed to document the clinical supervision core curriculum in personnel records #3, 14, and 15.
Personnel record #3 was hired as a clinical supervisor on 09/08/2009. There was no documentation that there was at least 2 years of being a supervisor in the provision of clinical services prior to the hiring. There was also no documentation that the clinical supervision core curriculum was completed prior to the date of the inspection.
Personnel record #14 was hired into the project on 7/24/2006 and was promoted to clinical supervisor on 11/01/2009. There was no documentation that there was at least 2 years of being a supervisor in the provision of clinical services prior to the promotion. There was also no documentation that the clinical supervision core curriculum was completed prior to the date of the inspection.
Personnel record #15 was hired into the project on 5/24/2004 and was promoted to clinical supervisor on 4/17/2011. There was no documentation that there was at least 2 years of being a supervisor in the provision of clinical services prior to the promotion. There was also no documentation that the clinical supervision core curriculum was completed prior to the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The three identified staff in clinical supervision positions will schedule and complete clinical supervision core curriculum training once DDAP is scheduled and registration opens.
2. In future Clinical Director will direct Administrative Assistant to schedule all new Clinical Supervisors for core curriculum training if indicated based on their professional experience.
3. The Clinical Director will assure corrective plan is completed for current and future Clinical supervisors.
4. Corrective Action Plan will be implemented immediately. The deficiency will be corrected as the scheduling of training sessions becomes available.
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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that their capacity for their Inpatient Non-Hospital Detoxification activity did not exceed the required licensed client capacity of 33.
The findings include:
The SRFSR was reviewed on August 31, 2015. According to the June 28, 2015 through July 25, 2015 primary staff schedule for the detox activity provided with the SRFSR, the facility had 34 clients on July 3, 2015, 38 clients on July 17, 2015, 35 clients on July 18, 2015, and 34 clients on July 19, 2015, which exceeded their licensed 33 detox client capacity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 31, 2015, the facility submitted a request for flex beds between our inpatient non-hospital detoxification activity and our inpatient non-hospital drug free activity. The request was approved on September 1, 2015 for the timeframe of January 1, 2015 through December 31, 2015. The maximum capacity for detox is 33 and the maximum capacity for inpatient drug-free is 82. The number of beds approved for flexing between the two activities is 9. The facility director will continuously monitor the detox census on a daily basis to ensure that it does not exceed the approved capacity with the flex beds included.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that a completed informed and voluntary consent to release information was obtained in four of twenty-six client records reviewed.
The findings included:
Twenty-six client records requiring a completed informed and voluntary consent to release information forms were reviewed from August 31, 2015 through September 2, 2015. The facility failed to ensure the specific purpose of the release of information was included on the consent to release information forms in client records, #1, 7, 9, and 10.
Client #1 was admitted into detox treatment on August 27, 2015 and was still an active client at the time of the inspection. A release of information form to a doctor was signed and dated on 08/29/2015; however; the release of information form did not include the purpose of the disclosure of information.
Client #7 was admitted into residential treatment on August 17, 2015 and was still an active client at the time of the inspection. Three separate release of information forms to an outside agency, a court system, and another treatment provider were signed and dated on 08/18/2015; however; all three release of information forms did not include the purposes of the disclosure of information.
Client #9 was admitted into residential treatment on August 8, 2015 and was still an active client at the time of the inspection. A release of information form to a doctor was signed and dated on 08/17/2015; however; the release of information form did not include the purpose of the disclosure of information.
Client #10 was admitted into residential treatment on May 31, 2015 and was discharged on June 24, 2015. A release of information form to a family member was signed and dated on 08/29/2015; however; the release of information form did not include the purpose of the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Director will direct and supervise Clinical counselors to review the consents with current clients and update identified consents in deficiency. Reviewed charts from survey are now closed as patients have been discharged. These charts will be utilized in mandatory training.
2. The Clinical Director along with Director of Admission will conduct education sessions regarding completion of informed and voluntary consent with special attention to purpose of disclosure area. These sessions will be mandatory for all staff.
3. Clinical Director and Director of Admissions will assure that this defined corrective action is completed. Clinical supervisors will conduct chart audits monitoring compliance after educational sessions are completed.
4. Corrective action will be completed by November 1, 2015.
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