INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16-19, 2017 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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704.11(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 facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee #17 received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe. Employee #17 was hired as a cook on 1/12/15 and was due to have HIV/AIDS training no later than 1/12/17. The HIV/AIDS training was completed on 10/3/17. There was no documentation in the personnel file of the completion of the TB/STD as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Departmental Supervisors are responsible to assign mandatory training to newly hired staff within specified time frames. HIV/AIDS and tuberculosis/STD training will be completed within 1 year for counselors/counselor assistants and within 2 years for non-clinical staff. Nurses and physicians are exempt. Department Supervisors will ensure compliance by collecting and providing to the PI Coordinator (or designee) staff Certificates of Completion for mandatory trainings. This standard will be reviewed at the December 2017 Leadership Meeting. The PI Coordinator (or designee) will maintain a list of all new hires and completion dates for mandatory trainings. PI Coordinator will oversee compliance by reviewing the staff list quarterly for compliance and presenting at Leadership Meetings if action is needed. Staff # 17 will be in compliance January 26, 2018. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on October 18, 2017 at approximately 11:00 A.M., it was observed that the facility failed to ensure there was proper ventillation in the central vented bathrooms. The exhaust fans were inoperable and the bathrooms did not have windows.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Monthly environment of care rounding tool used by staff was revised to include operability of patient bathroom exhaust fans in November 2017. Results of rounding will be provided to the Divisional Manager of Plant Operations who is responsible for timely maintenance, reporting resolutions to Safety/EOC Committee, and continued oversight and compliance to standard. Patient bathroom exhaust fans were fixed and operable October 25, 2017. In addition, cost for bathroom renovation has been budgeted for fiscal year 2018. |
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 the fire drill records from December 2016 to September 2017, the facility failed to document that fire drills were conducted during sleeping hours at least once every 6 months as there were no fire drills conducted during sleeping hours for the timeframe reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Mirmont Treatment Center will conduct a fire drill during sleeping hours at least once every 6 months. Divisional Manager of Plant Operations oversees the scheduling, conducting, and documenting of all fire drills. Divisional Manager of Plant Operations will complete a fire drill during sleeping hours by December 31, 2017 and will ensure compliance to this standard in the future. |
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 the review of 49 total client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 client record. Additionally, 10 client records had consent to release forms that were missing elements.Client #5 was admitted into the detox level of care on 8/22/17 and was discharged on 8/28/17. There was a consent form signed and dated on 8/23/17 to an agency; however, it did not include the purpose for disclosure.Client #11 was admitted into the inpatient nonhospital level of care on 9/17/17 and was discharged on 10/2/17. There was a consent form signed and dated on 9/19/17 to an agency; however, it did not include the purpose for disclosure. Additionally, there was a consent to release information form dated by the witness on 9/22/17 to an agency; however, it did not include the purpose for disclosure, or a dated client signature.Client #12 was admitted into the inpatient nonhospital level of care on 8/1/17 and was discharged on 8/26/17. There was a consent form signed and dated on 8/25/17 to an agency; however, it did not include the purpose for disclosure, or the information to be released. Client #13 was admitted into the inpatient nonhospital level of care on 8/28/17 and was discharged on 9/16/17. There was a consent form signed and dated on 8/23/17 to an agency; however, it did not include the purpose for disclosure. Additionally, there was another consent form signed on 9/12/17 to a government agency; however, it did not the purpose for the disclosure, or the information to be released.Client #19 was admitted into the partial hospitalization level of care on 10/2/17 and was an active client at the time of the inspection. There was a consent form signed and dated on 9/19/17 to an agency; however, it did not include the purpose for disclosure. Additionally, there was a consent to release information form dated by the witness on 9/22/17 to an agency; however, it did not include the purpose for disclosure, or a dated client signature.Client #20 was admitted into the partial hospitalization level of care on 8/28/17 and was discharged on 9/18/17. There was a consent form signed and dated on 8/25/17 to an agency; however, it did not include the purpose for disclosure, or the information to be released. Client #21 was admitted into the partial hospitalization level of care on 8/3/17 and was discharged on 8/23/17. There was a consent form signed and dated on 8/2/17 to psychiatrist; however, it did not include the purpose for disclosure.Client #25 was admitted into the outpatient level of care on 9/20/17 and was an active client at the time of the inspection. There was a consent form signed and dated on 8/25/17 to an agency; however, it did not include the purpose for disclosure, or the information to be released.Client #26 was admitted into the outpatient level of care on 8/25/17 and was an active client at the time of the inspection. There was a consent form signed and dated on 8/2/17 to psychiatrist; however, it did not include the purpose for disclosure.Client #27 was admitted into the outpatient level of care on 9/17/17 and was an active client at the time of the inspection. There was a consent form signed and dated on 8/23/17 to an agency; however, it did not include the purpose for disclosure. Additionally, there was another consent form signed on 9/12/17 to a government agency; however, it did not the purpose for the disclosure, or the information to be released.Client #29 was admitted into the outpatient level of care on 02/10/17 and was discharged on 3/22/17. There was a facsimile sent to an attorney on 2/27/17; however, there was no consent form on file prior to disclosure.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Identified consents have been reviewed and noted deficiencies have been updated with one active client. The remaining identified charts are closed but will be reviewed in mandatory staff training. Mandatory staff training is scheduled in December regarding proper and timely documentation of consents as well as completion of all elements on Release of Information forms. Clinical Supervisors will audit charts monthly and will supervise staff accordingly to ensure compliance going forward. These chart audits will be reviewed at monthly Performance Improvement Meetings. Supervision has occurred with staff responsible for the improper documentation found during the DDAP audit. In addition, Mirmont Treatment Center is scheduled to implement an electronic medical record (EMR) on May 1, 2017. Monthly compliance audit report will be developed within the EMR program. Results will be reviewed by Clinical Supervisors with staff found to not be in compliance with the standard. |
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 the review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.The incident dates and incident reasons are:December 28, 2016 - ambulance presence requested for client #29December 30, 2016- police presence requestedJune 5, 2017- ambulance presence requested. The incident was not reported until June 13,2017.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Departmental Supervisors will be responsible to re-educate staff on the importance of timely incident reporting. Mirmont Treatment Center Patient Safety Officer (PSO) is responsible to review these incidents and maintain compliance to standard by reporting unusual incidents to the State within mandated time frames. Fax transmission confirmations will be retained by PSO. Mirmont Treatment Center's Incident Reporting Policy will be revised to include reporting of unusual incidents to regulatory authorities within specified time frames. Revised policy will be distributed and clarified at mandatory staff training scheduled in December 2017. |