INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2008 through September 11, 2008 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. The following deficiencies were identified during this inspection and a plan of correction is due on October 20, 2008.
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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 personnel records and staff interview on September 10, 2008, the facility failed to document that a counselor who was appointed as lead counselor for the purposes of supervision of other counseling staff, was qualified for that position by having either 2 years of clinical supervision experience or by obtaining the core curriculum in clinical supervision training within six months of the date of appointment to lead counselor..
Findings:
The facility failed to document that the counselor selected to act as the lead counselor had two years of experience as a supervisor in the provision of clinical services or had completed a core curriculum in clinical supervision training within six months of the date of appointment to that position. The documentation was missing from the personnel record of employee #21.
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Plan of Correction
The lead counselor will complete the core training cirriculum to fulfill this requirement for supervision of all other counseling staff.
The Clinincal Supervisor will assist in finding the training and monitor for completion.
Full compliance will be acheived by March 2009 |
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
Based on a review of fire drill records on September 11, 2008, the facility failed to document a fire drill which took place during sleeping hours every six months.
Findings:
At the time of the licensing inspection, the facility failed to provide documentation of a fire drill taking place during sleeping hours every six months. Documentation for a fire drill during sleeping hours was provided for September 2007 and August 2008.
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Plan of Correction
Although Mirmont had documentation of conducting a fire drill during sleeping hours for Maech 2008, it was not in the Fire Drill Manual at the time of the inspection.
The Facilities Director will ensure that all fire drills are documented and placed in the Fire Drill manual in a timely fashion. The manual will be brought to and reported at the monthly safety/infection control meeting to monitor for ongoing compliance.
The missing fire drill documentation was placed in the Fire Drill Manual on September 12, 2008 |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents on September 9, 2008, the facility failed to document an annually updated written manual delineating project policies and procedures.
Findings:
The Project Director failed to provide written documentation that the manual delineating project policies and procedures was updated annually. The Project Director's most recent sign-off on the manual was dated December 15, 2006.
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Plan of Correction
The Project Director failed to provide written documentation delineating an annual review and updating of the policy and procedure manual.
The Performance Improvement Director will ensure that in January of each year, the review and updating of the policy and procedure manual will be completed along with the written documentatin from the Project Director delineating the review.
This documentation was placed in the policy and procdure manual as of October 7, 2008 for this year |
709.24(a)(4) 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:
(4) Written procedures for referral outlining cooperation with other service providers.
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Observations
Based on a review of the project's written policies and procedures manual on September 9, 2008, the facility failed to document written procedures for referral outlining cooperation with other service providers.
Findings:
The facility failed to document procedures for incoming and outgoing referrals.
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Plan of Correction
Mirmont failed to have a written procedure for referrals outlining incoming and outgoing referrals with other service providers.
The Director of Performance Improvement has written a policy outlining the procedure staff is to follow for incoming and outgoing referrals to other service providers.
The new policy will be distributed to all department heads who will in-service their staff on the new procdeure. Mirmont will be fully compliant with the procdeure by November 14, 2008
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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
Based on a review of eight client records on September 10, 2008, it was determined that the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward and ability to participate in treatment, and overall impressions in five of eight client records where required.
Findings:
A review of client record #3 indicated that the clinician failed to document the client's assets/strengths, support systems, client's attitude toward and ability to participate in treatment, as well as overall impressions based on the clinician's analysis of the collected historical information. Client record #6 was missing the counselor's conclusions/impressions. Client records #7, 8, and 19 did not document evaluations based on supporting documentation from the intake process, rather relied on client perceptions to formulate the evaluation.
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Plan of Correction
The Clinical Director will hold an inservice for the counselors on completing the psychosocial evaluation which will include the clinicians analysis of the patient's problems/needs, assets/strengths, support system, coping mechanisms, negative factors, attitude toward and ability to participate in treatment, and the clinicians overall impression of the client upon completion of the biopsychosocial assessment.
Compliance will be achieved by November 26, 2008
The Clinical Director will monitor for compliance. |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on a review of administrative records on September 9, 2008, the facility failed to provide documentation of the facility's ability to assist the client in obtaining educational support services.
Findings:
The facility failed to provide documentation of a letter of agreement or documentation of attempts to assist the clients in obtaining educational support services.
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Plan of Correction
The Administratvie Assistant to the CEO has contacted Delaware County Community College and has obtained a letter of agreement to assist the clients in obtaining educational support services.
This letter of agreement was obtained by September 18, 2008.
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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
Based on a review of eight client records on September 11, 2008, it was determined that the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward and ability to participate in treatment, and overall impressions in five of eight client records.
Findings:
The facility failed to document coping mechanisms for three of eight client records where required, specifically client records #11, 23, and 24.
The facility failed to document client problems/needs in one of eight client records where required, specifically client record #9.
The facility failed to document negative factors that might affect treatment in one of eight client records reviewed, specifically client record #12.
The facility failed to document the client's attitude toward and ability to participate in the treatment process in two of eight client records reviewed, specifically client records #11 and 23.
The facility failed to document the counselors' overall conclusions/impressions in two of eight client records reviewed, specifically client records #23 and 24.
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Plan of Correction
The Outpatient Clinical Supervisor will hold an inservice for all staff to ensure that a completed biopsychosocial contains the clinicians analysis of the following: the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward and ability to participate in treatment, and the clinicians overall impressions of the client.
Mirmont will be in full compliance by January 14, 2009.
The Outpatient Clinical Supervisor will monitor cor compliance. |