INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2023 through September 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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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 records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of seven applicable personnel records reviewed.
Employee #10 was hired as a counselor on December 27, 2021. The TB/STD training should have been completed no later than December 27, 2022; however, there was no documentation of the training at the time of the inspection.
Employee #14 was hired as a counselor on November 1, 2021. The TB/STD training should have been completed no later than November 1, 2022; however, the TB/STD training was not completed until July 14, 2023.
This is a repeat citation from the September 12, 2022 through September 13, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Departmental supervisors are responsible to assign mandatory training to newly hired staff within specified timeframes. HIV/AIDS and tuberculosis/STD training will be completed within 1 year for counselors/counselor assistants and within 2 years for non-clinical staff. Department supervisors will within the first week of orientation ensure that the staff member has registered for mandatory classes on the DDAP training websites at the earliest appointment available. If an appointment is not available on the DDAP websites, the staff will be scheduled for the 1st available training provided onsite which is scheduled in advance twice per year. Supervisors will collect certificates of completion and provide to Quality Manager (or designee) who maintains a list of due dates for mandatory trainings for all staff members. Training date reminders will be sent to staff and supervisors 2 weeks prior to training and confirmation for planned attendance will be communicated by supervisor. Plan of correction and process reviewed at Leadership meeting 9/11/2023. Employee #10 will be in compliance 9/25/2023. |
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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.
Client #3 was admitted on October 31, 2022 and was discharged on November 8, 2022. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The identified chart with incorrect Release of Information was reviewed during departmental supervision in September. Re-education was provided including the proper and timely documentation of Releases of Information as well as completion of all elements on Release of Information forms. Departmental supervisors will audit charts monthly and will supervise staff accordingly to ensure compliance going forward. Supervision has occurred with staff responsible for the improper documentation found during the DDAP audit. New Release of Information document types were created in the electronic medical record on 9/15/2023 making it easy to see what Releases have been obtained - and therefore what Releases still need to be obtained. A monthly compliance report will be developed within the EMR program. Results will be reviewed by Department Supervisors with staff found to not be in compliance with the standard. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent form in one of fourteen client records reviewed.
Client #9 was admitted on August 21, 2023 and was still active at the time of inspection. A release of information form was signed and dated by the client on August 21, 2023 and the release form did not include a name of a person, agency, or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The identified chart with incorrect Release of Information was reviewed during departmental supervision in September. Re-education was provided including the proper and timely documentation of Releases of Information as well as completion of all elements on Release of Information forms. Departmental supervisors will audit charts monthly and will supervise staff accordingly to ensure compliance going forward. Supervision has occurred with staff responsible for the improper documentation found during the DDAP audit. In addition, Quality Manager has requested that the 'Name of Person or Institution' be a mandatory field for input on the Release of Information contained in the electronic medical record. A monthly compliance report will be developed within the EMR program. Results will be reviewed by Department Supervisors with staff found to not be in compliance with the standard.
Patient discharged 9/14/2023. The Release of Information was not corrected prior to discharge. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an incident at the facility requiring the presence of police, fire, or ambulance personnel.
On May 24, 2023, there was an incident involving the presence of ambulance personnel onsite and was not reported to the Department within 3 business days. The incident was reported on May 31, 2023.
On February 11, 2023, there was an incident involving the presence of police personnel and was not reported to the Department within 3 business days. The incident was reported on March 31, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
4. The two identified incidents were reviewed with the Patient Safety Specialist that is responsible for reporting to DDAP. It was discovered that the Patient Safety Specialist did not receive the information within the timeframe required to appropriately report to DDAP. A new process has been implemented at the daily 9AM interdisciplinary Safety Huddle. At the Safety Huddle, departments now report events of the prior day that could warrant DDAP reporting. Patient Safety Specialist confirms if a report is needed. If a DDAP report is required, Patient Safety Specialist submits all pertinent data within the required time frame. |