INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30- October 2, 2013, 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.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the staff development and training documentation, the facility failed to provide an evaluation of the training activities for the previous training year.
The finding includes:
The staff development plan for the facility was reviewed on September 30, 2013. The annual evaluation of the overall training plan consisted of a summary of the training received by facility staff but failed to evaluate the extent to which the plan addressed the identified training needs, including a determination of the extent to which implementing the plan eliminated or satisfied the identified training needs for the facility staff.
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Plan of Correction
The Project Director or designee will complete an annual evaluation of Mirmont's training plan that shall include the following components:
a. a summary of the training received by the facility
b. an evaluation of how well the plan addressed Mirmont's training needs
c. an evaluation of how well the plan did or did not address the identified needs of the staff.
The annual evaluation will be reviewed at the January 2014 leadership meeting to ensure all elements of the plan have been discussed and met |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on September 30, 2013, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on September 30, 2013. The outpatient caseload computation sheet listed seven counselors and two clinical supervisors, as clinical staff. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week 40, and the total number of clients assigned to the following employees on September 30, 2013 employee # 8 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 8 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 15 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee #8 had 17 active clients.
Employee # 8 (15/35 = .428 FTE 17 clients/.428 FTE = 40:1 caseload)
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Plan of Correction
The President and PI Director met with the Outpatient Director to review the outpatient staff caseload and how it is determined on October 22, 2013. The Outpatient Director or designee will meet with all the outpatient staff to review their time keeping behaviors.
The Outpatient Director or designee will monitor each staff members caseload monthly to ensure compliance with State standard ratio or of 35:1 or less. Any discrepancies will be reported to the PI Driector and corrected immediately |
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 the informed and voluntary consent form was properly completed in six of eleven records reviewed.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013. Eleven records were reviewed for documented informed voluntary consent forms. The facility failed to ensure the required information was completed on the informed voluntary consent forms in client records # 8, 9, 11, 13, 14 and 21.
Record # 8 had an informed voluntary consent to release for the treatment facility to release information to their outpatient program. The consent had "other" checked off, but the staff did not indicate what was going to be released.
Record # 9 had an informed voluntary consent to release for the client's parents. The release failed to include the purpose for the release and a staff/witness signature.
Record # 11 had an informed voluntary consent to release for the client's parents. The release failed to include the purpose for the release.
Record # 13 had an informed voluntary consent to release for the client's spouse. The release failed to include the purpose for the release.
Record # 14 had an informed voluntary consent to release for a police department. The consent had "other" checked off, but the staff did not indicate what was going to be released and did not indicate whether the client received a copy of the consent form. Additionally, there was a release for the client's insurance company in the record that did not include the purpose for the release.
Record # 21 had a consent for an emergency referral documented that failed to include what information would be released and the purpose of the consent was not documented.
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Plan of Correction
The PI Director will meet with the admissions department; nursing department; UM department, and counseling department and their managers to hold an in-service to re-educate the staff on Confidentiality laws/standards in Pa. This will include directions on how to properly complete a Release of Information form. The in-services will be completed during their staff meeting in November or December.
To monitor compliance, the PI Director or designee along with the department managers will monitor a minimum of 2 patient charts/week (10 charts) and report any issues at the bi-monthly Leadership meeting. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician, as required by regulation and facility policy and procedure, in one of six client records.
The findings include:
Six detoxification client records were reviewed on October 1-2, 2013. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Client record # 9 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient #9 was admitted on September 27, 2013. A verbal Skype order was documented in the record from the physician to the Certified Registered Nurse Practitioner on September 28, 2013 at 6:00 a.m. The order was not signed by the prescribing physician as of the date of the inspection.
The above information was confirmed by staff and was not disputed.
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Plan of Correction
The Medical Director and Nurse manager will hold a medical/nursing staff meeting on November 6, 2013 to re-educate the staff on Mirmont's verbal order policy, which requires the prescribing physician/CRNP to sign all verbal orders within 24 hours. As well as review the 24hr chart check procedure that is completed nightly by nursing.
To ensure that this occurs the Prescribing physician/CRNP giving the verbal orders will be the phycian/CRNP who is rounding and signing any verbal orders that he/she gave the next day. All charts requiring signature will be pulled by nursing during chart checks.
The PI department or nursing designee will monitor compliance.
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of two client records.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013. Ten records were discharged client records. Two records required written notification to the client informing him/her of the decision to terminate the client's treatment. The facility failed to document written notification to the client of the decision to involuntarily terminate their treatment in record #14.
This finding was discussed with the clinical supervisor on October 2, 2013 and was not disputed.
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Plan of Correction
The Pi Director or designee along with the nurse manager and Clinical Supervisors will conduct an in-service to educate/re-educate staff on the involuntary discharge policy and procedure.
The Pi Director or designee will monitor all involuntary discharges to ensure compliance. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision to terminate treatment in one of two client records.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013. Ten records were discharged client records. Two records required the facility to give the client an opportunity to request reconsideration of a decision to terminate treatment. The project did not document that the client was given an opportunity to request reconsideration in client record # 14.
This finding was discussed with the clinical supervisor on October 2, 2013 and was not disputed
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Plan of Correction
The Pi Director or designee along with the nurse manager and Clinical Supervisors will conduct an in-service to educate/re-educate staff on the involuntary discharge policy and procedure, which includes the patient's request for reconsideration of the decision.
The Pi Director or designee will monitor all involuntary discharges to ensure compliance
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709.62(c)(3)(i) LICENSURE Medical history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of the client records, the facility failed to document a detailed drug and alcohol history that included the client's progression of drug or alcohol use in one of five records reviewed. Additionally, five of five records reviewed failed to include a complete personal history that included the client's prior treatment,client's perception of drug and alcohol use, family, legal, employment/vocation, educational, military, recreational and sexual history
The findings include:
Twenty-one client records were reviewed October 1-2, 2013. Five short-term detoxification client records were reviewed for drug and alcohol history's and personal history's that included prior treatment, client's perception of drug and alcohol use, family, legal, employment/vocation, educational, military, recreational, and sexual history. Client records # 9, 10,11,12 and 13 lacked detailed personal histories. client record # 10 failed to include a drug and alcohol history that included the client's progression of drug or alcohol use.
Client record # 9 failed to include a detailed legal history,and employment/vocational history.
Client record # 10 failed to include the client's progression of drug and alcohol use, client's perception of drug and alcohol use, a detailed employment/vocational history and detailed educational history.
Client record # 11 failed to include a detailed legal history, employment/vocational history and sexual history.
Client record # 12 failed to include a detailed legal history, employment/vocational history and sexual history.
Client record # 13 failed to document a detailed recreational history and sexual history.
These findings were reviewed with the facility staff and were not disputed.
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Plan of Correction
The Clinical Director along with the Clinical Supervisors will re-educate the counseling staff on the Biopsychosocial policy. This will include an emphasis on providing detail for each category of the patient's history, which includes a drug and alcohol historythat ncludes the progression of the patient's D&A use.
To assist with this, the Clinical Supervisors will revise the Biopsychosocial to include more cues to ensure a complete history. The revised Biopsychosoical will also be reviewed with staff at the November staff meeting
The Clinical Supervisors will monitor a minimum of 1 chart for each counselor on a weekly basis to ensure compliance and report their finding weekly to the Clinical Director.
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709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of the client records, the facility failed to document a detailed drug and alcohol history that included the client's progression of drug or alcohol use in three of eight records reviewed. Additionally, two of eight records reviewed failed to include a complete personal history that included the client's prior treatment,client's perception of drug and alcohol use, family, legal, employment/vocation, educational, military, recreational and sexual history.
The findings include:
Twenty-one client records were reviewed October 1-2, 2013. Eight residential client records were reviewed for drug and alcohol history's and personal history's that included prior treatment, client's perception of drug and alcohol use, family, legal, employment/vocation, educational, military, recreational and sexual history. Client records # 16 and 17 lacked detailed personal histories. Client records # 8, 15 and 16 failed to include a drug and alcohol history that included the client's progression of drug or alcohol use.
Client record # 8 failed to include the client's progression of drug and alcohol use.
Client record # 15 failed to include the client's progression of drug and alcohol use.
Client record # 16 failed to include the client's progression of drug and alcohol use and did not include a detailed employment/vocational history.
Client record # 17 failed to include a detailed employment/vocational history.
These findings were reviewed with the facility staff and were not disputed.
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Plan of Correction
Plan of Correction:
The Clinical Director along with the Clinical Supervisors will re-educate the counseling staff on the Biopsychosocial policy. This will include an emphasis on providing detail for each category of the patient's history, which includes a drug and alcohol historythat ncludes the progression of the patient's D&A use and a complete personal history (education, legal, family, employment, etc).
To assist with this, the Clinical Supervisors will revise the Biopsychosocial to include more cues to ensure a complete history. The revised Biopsychosoical will also be reviewed with staff at the November staff meeting
The Clinical Supervisors will monitor a minimum of 1 chart for each counselor on a weekly basis to ensure compliance and report their finding weekly to the Clinical Director.
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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 upon a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets and strengths, support systems, negative factors, attitude toward treatment and/or failed to document a psychosocial evaluation.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013, seven inpatient records were reviewed for psychosocial evaluations. Six of seven records lacked documentation of a psychosocial evaluation that included an assessment of the patient's assets and strengths, support systems, negative factors, attitude toward treatment, specifically records # 7, 15, 16, 17, 20 and 21. One out of seven records lacked a psychosocial assessment, record # 8.
Client # 7 was admitted on June 11, 2013. The psychosocial assessment failed to include an evaluation by the counselor that included an assessment of the client's support systems.
Client # 8 was admitted on May 26, 2013 and discharged on June 26, 2013. The psychosocial evaluation is required to be completed as a part of the intake and admission of a new patient. As of the date of the inspection, there was no documentation of a psychosocial assessment for patient # 8.
Client # 15 was admitted on September 4, 2013. The psychosocial evaluation is required to be completed as a part of the intake and admission of a new patient. The psychosocial assessment failed to include an evaluation by the counselor that included an assessment of the client's problems/needs, assets/strengths and support systems.
Client #16 was admitted on September 9, 2013. The psychosocial assessment failed to include an evaluation by the counselor that included and assessment of the client's support systems.
Client # 17 was admitted on September 3, 2013. The psychosocial assessment failed to include an assessment by the counselor that included an assessment of the client's problems/needs, support systems and coping mechanisms.
Client # 20 was admitted on August 22, 2013. The psychosocial assessment failed to include an evaluation by the counselor that included and assessment of the client's assets/strengths and coping mechanisms.
Client # 21 was admitted on August 31, 2013. The psychosocial assessment failed to include an evaluation by the counselor that included and assessment of the client's problems/needs, coping mechanisms, negative factors, and the counselor's conclusions and impressions.
These findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
The Clinical Director along with the Clinical Supervisors will re-educate the counseling staff on the Biopsychosocial policy. This will include an emphasis on providing detail for each category of the patient's history, which includes an assessment of the patient's assests and strengths, support systems, negative factors, and attitude towards treatment and all other areas of the psychosocial assessment(drug and alcohol history including the progression of use education, legal, family, employment, etc).
To assist with this, the Clinical Supervisors will revise the Biopsychosocial to include more cues to ensure a complete history. The revised Biopsychosoical will also be reviewed with staff at the November staff meeting
The Clinical Supervisors will monitor a minimum of 1 chart for each counselor on a weekly basis to ensure compliance and report their finding weekly to the Clinical Director.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document a complete history that included medical, drug or alcohol history, and personal history in three of five records reviewed.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013. Eight outpatient records were reviewed and five of those records were reviewed for client histories. The facility failed to document a detailed drug and alcohol history that included their progression of use in client records # 1, 2 and 8. Client record # 1 also failed to include a detailed educational history.
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Plan of Correction
The Outpatient Clinical Director will re-educate the counseling staff on the Biopsychosocial policy. This will include an emphasis on providing detail for each category of the patient's history, which includes a detailed D&A history with progression of usage; detailed personal history which includes educational, employment, sexual, etc and an assessment of the patient's assests and strengths, support systems, negative factors, and attitude towards treatment.
To assist with this, the Clinical Supervisors will revise the Biopsychosocial to include more cues to ensure a complete history. The revised Biopsychosoical will also be reviewed with staff at the November staff meeting
The Outpatient Clinical Supervisor or designee will monitor a minimum of 1 chart for each counselor on a weekly basis to ensure compliance and report their finding weekly to the Outpatient Director.
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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 upon a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets and strengths, support systems, negative factors, attitude toward treatment and/or failed to document a psychosocial evaluation.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013, seven outpatient records were reviewed for psychosocial evaluations. Five out of seven records lacked documentation of a psychosocial evaluation that included an assessment of the patient's assets and strengths, support systems, negative factors, attitude toward treatment, specifically records # 2, 6 and 7. Two out of seven records lacked a psychosocial assessment, records # 4 and 8.
Client # 2 was admitted on June 20, 2013. The psychosocial assessment failed to include an evaluation by the counselor that included an assessment of the client's problems/needs and support systems. The documentation did not include an evaluation by the clinician for the required components.
Client # 4 was admitted on June 2, 2013. The psychosocial evaluation is required to be completed as a part of the intake and admission of a new patient. As of the date of the inspection, there was no documentation of a psychosocial assessment for patient # 4 in the client record.
Client #6 was admitted on April 29, 2013. The psychosocial assessment failed to include an evaluation by the counselor that included support systems.
Client #7 was admitted on June 11, 2013. The psychosocial assessment failed to include an evaluation by the counselor that included an assessment of the patient's support systems.
Client # 8 was admitted on May 26, 2013 and discharged on June 26, 2013. The psychosocial evaluation is required to be completed as a part of the intake and admission of a new patient. As of the date of the inspection, there was no documentation of a psychosocial assessment for patient # 8.
These findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
The Outpatient Clinical Director will re-educate the counseling staff on the psychosocial policy during their November staff meeting. This will include an emphasis on providing detail for each category of the patient's history, which includes an assessment of the patient's asssets and strengths, support systems, negative factors, attitude toward treatment, a detailed D&A history and personal history which includes educational, employment, sexual, etc.
To assist with this, the Clinical Supervisors will revise the Biopsychosocial to include more cues to ensure a complete history. The revised Biopsychosoical will also be reviewed with staff at the November staff meeting
The Outpatient Clinical Supervisor or designee will monitor a minimum of 1 chart for each counselor on a weekly basis to ensure compliance and report their finding weekly to the Outpatient Director.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document a treatment and rehabilitation plan at least every sixty days in one of three records reviewed.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013. Three outpatient records required treatment plan updates. The facility failed to document at treatment plan update in client record # 3.
Client # 3 was admitted on July 2, 2013 and discharged on September 19, 2013. The treatment and rehabilitation plan update was due September 7, 2013.
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Plan of Correction
The Outpatient Clinical Director will re-educate the counseling staff on Mirmont's treatment plan policy (based on State standards) during their November staff meeting. This will include an emphasis on both the time frame for updated and initial treatment plans.
The Outpatient Clinical Supervisor or designee will monitor a minimum of 1 chart for each counselor on a weekly basis to ensure compliance and report their finding weekly to the Outpatient Director
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709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of client records, the facility failed to have a complete record in four of eight records reviewed.
The findings include:
Twenty-one client records were reviewed on October 1-2, 2013. Eight outpatient records were reviewed and five records required a discharge summary within seven days of the client's discharge. The facility failed to document a discharge summary within seven days of discharge in client records # 6 and 8. Additionally, the facility is required to conduct follow-up on all discharges. According to the facility's policy, follow-up will be documented within seven days of discharge. The facility failed to document follow-up in client records # 5, 7, and 8.
Client # 5 was admitted on June 3, 2013 and left against medical advice on June 10, 2013. Follow-up was required by June 17, 2013. The facility failed to document follow-up for this client as of the date of the inspection.
Client # 6 was admitted on April 29, 2013 and discharged on June 14, 2013. Based on the documentation on the discharge summary, the discharge summary was dictated on July 16, 2013 and typed on July 17, 2013. The documentation showed the discharge summary was completed late.
Client # 7 was admitted on June 19, 2013 and left the facility against facility advice. A termination letter dated June 26, 2013 was documented in the record informing the client of their discharge from the program. Follow-up was required by August 3, 2013. The facility failed to document follow-up for this client as of the date of the inspection.
Client # 8 was admitted on June 28, 2013. Documentation in the record revealed a termination letter dated July 3, 2013. Follow-up and the discharge summary were required by July 10,2013. The facility failed to document follow-up for this client as of the date of the inspection. The discharge summary was documented on July 18, 2013, eight days late.
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Plan of Correction
The Outpatient Clinical Director will re-educate the counseling staff on Mirmont's policy for sompletion of a discharge chsrt (which is based on State standards) during their November staff meeting. This will include an emphasis on the time frame for discharge summary completion. As well as the completion of a Continuing Care Plan for each patient discharged regardless of the type of discharge and a copy of which will be given to the PI Department for compliance with follow up within 7 days of discharge from the program/facility.
The Outpatient Clinical Supervisor or designee will monitor a minimum of 1-2 discharge charts for each counselor on a monthly basis to ensure compliance and report their finding weekly to the Outpatient Director
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