INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from October 9 - 12, 2012, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based upon the review of administrative documentation and employee records, the facility failed to develop an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor.
The findings include:
As per administrative documentation, the facility's training year runs from January 1 to December 31. Individual training plans are to be completed by the end of January for the current year.
Fourteen employee records requiring documentation of an individualized training plan were reviewed from October 11 - 12, 2012. Two of fourteen records, specifically #'s 14 and 15, did not contain an individual training plan for 2012.
Employee # 14, a nurse, was hired on March 5, 2005, and an individual training plan was due by January 31, 2012. As of the time of inspection, the record did not contain an individual training plan.
Employee # 15, a nurse, was hired on August 30, 2010, and an individual training plan was due by January 31, 2012. As of the time of inspection, the record did not contain an individual training plan.
The findings were confirmed by the Executive Administrative Assistant during the record review.
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Plan of Correction
Each staff member shall have a signed/dated individualized annual written training plan. It shall be the responsibility of the department head to ensure that each staff member completes one annually. The SGD coordinator will monitor for compliance by March of each year and report any deficiencies back to the department head. Completion of all forms/documents in a timely manner will be reflected in staffs' annual evaluation.
The 2 employees, 14 and 15, developed another 2012 training plan, signed it and that training plan was placed in thier personnel file. This was completed by November 15, 2012. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that heaters that are not permanently mounted or installed are not permitted in the facility.
The findings include:
The physical plant inspection was conducted on October 11, 2012, from approximately 9:00 AM to 10:30 AM.
A portable space heater was located inside a closet in a counselor's office.
The findings were confirmed by the Project Director during the exit interview.
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Plan of Correction
The Director of Facilities removed and diposed of the heater on 10/22/12. He has developed a policy stating no portable heating devices may be used or housed within the facility. All staff will be educated on the policy. Compliance will be monitored by the Safety/Infection Control Committee as part of their quarterly Safety Rounds and compliance will be recorded on the Safety Rounds Form to be presented at the Safety/Infection Control meeting |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon the review of the facility's fire drill logs, the facility failed to prepare and utilize alternate exits during fire drills.
The findings include:
The facility maintained two separate fire drill logs, one for the inpatient building and one for the outpatient building.
Fire drill logs for both buildings, for the period of November 2011 to October 2012, were reviewed on October 12, 2012.
The fire drill logs for both buildings included the following documentation:
"What exits were blocked? None
What exits were used? All exits were available -or- All other exits were available."
The documentation revealed that the facility failed to use alternate exits for fire drills conducted from November 2011 to October 2012.
The findings were confirmed during the exit interview with the Project Director.
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Plan of Correction
The Facilities Director or designee performing the monthly fire drills for both the inpatient and outpatient buildings will record which exit from the facility was blocked in the fire drill report. Compliance with this will be monitored at the monthly Safety/Infection Control meeting by review and discussion of the fire drills. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon a review of administrative documentation, the project failed to have an independent public accountant complete an annual audit of financial activities associated with the project's drug/alcohol abuse services upon conclusion of the fiscal year.
The findings include:
Administrative documentation, including the project's annual fiscal audit, was reviewed on October 9, 2012. As per policy, the project adheres to a traditional fiscal year of July 1 to June 30.
The project's fiscal audit for the time frame of July 1, 2010 to June 30, 2011, was late as it was dated February 6, 2012.
The findings were confirmed by the Project Director during the exit interview.
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Plan of Correction
The President of Mirmont (Project Director) will work with our Parent Company to ensure that our annual audit is completed within a timely manner. The President has requested to receive the audit as soon as it is completed. That Mirmont's audit will be puuled out from the entire corporate audit to compley with the State standard . |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
Based upon a review of employee records and administrative documentation, the facility failed to demonstrate that employees were advised of their right to inspect their own records.
The findings include:
Administrative documentation and three employee records requiring verification of employee rights notification were reviewed on October 12, 2012. The facility was unable to demonstrate that three of three new employees, specifically #'s 6, 7, and 8 were advised of their right to inspect their own records.
Employee # 6 was hired on February 23, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 7 was hired on February 6, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 8 was hired on November 14, 2011. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
The findings were reviewed with the Human Resources Representative during the employee record review.
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Plan of Correction
The SGD Coordinator and the Human Resources Coordinator have developed a process where the MLHS Day 1 Orientation sign-in sheet will be faxed to Mirmont and be placed in the employee's SGD file to show documentation that the employee was advised on their right to inspect their own records. The SGD Coordinator will monitor by completing an audit of each employee's SGD file for adherence to process.
The employees 6,7,&8 were given a copy of the revised policy, they read, signed and dated the policy which was put into their personnel file as of 11/15/2012 |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual, administrative documentation and employee records, the facility failed to develop and subsequently inform employees of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from their record.
The findings include:
The P&P Manual and administrative documentation were reviewed from October 9 - 10, 2012. Neither the manual nor the administrative documentation contained a policy that outlined the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the record.
In addition, the facility was unable to demonstrate its efforts toward informing staff of their right. Three employee records requiring verification of employee rights notification were reviewed on October 12, 2012. The facility was unable to demonstrate that three of three new employees, specifically #'s 6, 7, and 8 were advised of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 6 was hired on February 23, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 7 was hired on February 6, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 8 was hired on November 14, 2011. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
The findings were reviewed with the Human Resources Representative during the record review.
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Plan of Correction
The PI Director developed a policy that includes the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the record. The revised policy was approved at Mirmont's Medical-Clinical Operations Meeting on October 17, 2012. This revised policy is being given to each new employee as part of their Day 2 orientation, where they sign a form that states they have recieved and read the policy. This is then plced in their personel file. The Administrative Assistant who performs Day 2 orientation, completes an audit at the end of Day 2 to ensure that all orientation forms have been obtained,signed, and placed into the eployees file. If anything is missing, the Administrative Assistant will obtain the missing forms, signatures, etc. to ensure completion of the employees file within 7 days of hire.
An audit of all the personel files will be completed annually in September to ensure compliance prior to the State survey.
Employees 6,7,& 8 were given copy of the revised policy, which they signed and dated. This was placed in their personel files on 11/15/12 |
709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based upon a review of employee records and administrative documentation, the facility failed to demonstrate that employees were advised of their right to submit rebuttal data or memoranda to his records.
The findings include:
Administrative documentation and three employee records requiring verification of employee rights notification were reviewed on October 12, 2012. The facility was unable to demonstrate that three of three new employees, specifically #'s 6, 7, and 8 were advised of their right to submit rebuttal data or memoranda to his records.
Employee # 6 was hired on February 23, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 7 was hired on February 6, 2012. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
Employee # 8 was hired on November 14, 2011. As of the time of review, the facility was unable to provide documentation that verified that the employee was notified of their right specified above.
The findings were reviewed with the Human Resources Representative during the record review.
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Plan of Correction
The PI Director developed a policy that includes the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the record as well as submitting a rebuttal or memoranda to their record. The revised policy was approved at Mirmont's Medical-Clinical Operations Meeting on October 17, 2012. This revised policy is being given to each new employee as part of their Day 2 orientation, where they sign a form that states they have recieved and read the policy. This is then plced in their personel file. The Administrative Assistant who performs Day 2 orientation, completes an audit at the end of Day 2 to ensure that all orientation forms have been obtained,signed, and placed into the eployees file. If anything is missing, the Administrative Assistant will obtain the missing forms, signatures, etc. to ensure completion of the employees file within 7 days of hire.
An audit of all the personel files will be completed annually in September to ensure compliance prior to the State survey.
Employees 6,7,& 8 were given copy of the revised policy, which they signed and dated. This was placed in their personel files on 11/15/12. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based upon the review of personnel records, the facility failed to ensure that each employee signed a job description relevant to their specific job title, duties, and requisite skills, knowledge and experience.
The findings include:
Eight employee records requiring signed job descriptions were reviewed on October 11, 2012. Three of eight records, specifically # ' s 11, 14, and 15 contained job descriptions that were not signed by the employee.
Employee # 11, a nurse, was hired on January 7, 2009. The job description presented during the inspection was not signed by the employee.
Employee # 14, a nurse, was hired on March 5, 2005. The job description presented during the inspection was not signed by the employee.
Employee # 15, a nurse, was hired on August 30, 2010. The job description presented during the inspection was not signed by the employee.
The findings were confirmed by the Executive Administrative Assistant.
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Plan of Correction
The Human Resource Coordinator has provided the SGD Coordinator a copy of all job descriptions used at Mirmont. The SGD Coordinator has distributed the job descriptions to all department managers who are having staff sign and return the job description to SGD Coordinator. This shall be completed no later than December 31, 2012. The SGD Coordinator will perform an audit of all SGD files in December to ensure compliance in existing files. For each new hire, the SGD Coordinator will have the employee sign a copy of his/her job description during Day 2 Orientation, which occurs at Mirmont |
709.26(f)(1) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(1) Job title.
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Observations
Based upon the review of personnel records, the facility failed to ensure that each employee signed a job description relevant to their specific job title.
The findings include:
Eight employee records requiring signed job descriptions were reviewed on October 11, 2012. Three of eight records, specifically #'s 11, 14, and 15 contained job descriptions that were not signed by the employee.
Employee # 11, a nurse, was hired on January 7, 2009. The job description presented during the inspection was not signed by the employee.
Employee # 14, a nurse, was hired on March 5, 2005. The job description presented during the inspection was not signed by the employee.
Employee # 15, a nurse, was hired on August 30, 2010. The job description presented during the inspection was not signed by the employee.
The findings were confirmed by the Executive Administrative Assistant.
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Plan of Correction
The Human Resource Coordinator has provided the SGD Coordinator a copy of all job descriptions used at Mirmont. The SGD Coordinator has distributed the job descriptions to all department managers who are having staff sign, review, and return the job description to SGD Coordinator. This shall be completed no later than November 30, 2012. The SGD Coordinator will perform an audit of all SGD files in December to ensure compliance in existing files. For each new hire, the SGD Coordinator will have the employee sign a copy of his/her job description during Day 2 Orientation, which occurs at Mirmont. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon the review of client records, the facility failed to develop individualized treatment and rehabilitation plans with each client.
The findings include:
Four records requiring individualized treatment plans were reviewed from October 11 - 12, 2012. Two of four records, specifically #'s 6 and 7, contained treatment plans that were not individualized to the needs of the client.
Client # 6 was admitted on September 8, 2012, and was still an active client at the time of inspection. The record contained a treatment plan that was signed and dated by the client on September 14, 2012. Except for the name, date, and a few words, the treatment plan goals, objectives, and assignments for client # 6 were the same as the treatment plan signed by client # 7.
Client # 7 was admitted on September 13, 2012, and was still an active client at the time of inspection. The record contained a treatment plan that was signed and dated by the client on September 19, 2012. Except for the name, date, and a few words, the treatment plan goals, objectives, and assignments for client # 7 were the same as those on the treatment plan signed by client # 6.
The findings were confirmed by the Clinical Director during the record review.
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Plan of Correction
The Clinical Supervisor will hold an in-service for all counselors which will address how to individualize treatment care plans that are based on the needs of the client. The Clinical Supervisor or designee will monitor treatment care plans during individual supervision and by chart review and ensure compliance on a monthly basis.
The Clinical Supervisor met on a 1:1 session with the counsleor for clients #6 & 7 to discuss how to individualize their treatment care plans as well as all future treatment care plans when dealing with relapse syndrome. The counselor verbalized understanding of how to individualize treatment plans This was done on October 24, 2012 |