INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Buprenorphine Monitoring conducted on October 22, 2019 through October 24, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document the instruction in the use of fire extinguishers upon employment in 1 of 14 personnel records reviewed.Employee # 1 was hired as the Project Director on May 13, 2019. The fire extinguisher training was not completed until October 23, 2019.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The assignment for training and instruction of fire equipment will have a 5 day deadline built into the computer based program. The office manager will review utilizing checklist that all new employees meet this deadline. The office manager will communicate to the new employee supervisor of any staff that fail to meet this deadline allowing for 2 additional days to meet compliance.
Employee #1 completed training. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to ensure that all personnel, on all shifts, were trained to perform assigned tasks during emergencies in 1 of 14 personnel records reviewed.Employee # 1 was hired as the Project Director on May 13, 2019. The emergency training was not completed until October 23, 2019.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The assignment for training and instruction of assigned tasks during emergencies will have a 5 day deadline built into the computer based program. The office manager will review utilizing checklist that all new employees meet this deadline. The office manager will communicate to the new employee supervisor of any staff that fail to meet this deadline allowing for compliance for with in a week..
Employee #1 completed training. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to maintain all patient records in locked storage containers at all times as there was client-identifying information discovered unsecured on the desk in the psychiatrist's office.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff retrained on the security of patient information at debrief/unit team meetings. Medical Director reviewed standard with psychiatry team. Security assure all office doors locked on rounds.
Security and patient confidentiality added to environmental rounds which are monthly conducted and reviewed at monthly meetings. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on consent to release information forms in 3 of 16 client records reviewed.Client # 6 was admitted into the inpatient non-hospital detoxification level of care on November 14, 2017 and was discharged on November 19, 2017. There was a consent to release information form to a family member signed and dated by the client on November 15, 2017; however, the consent form did not include a purpose for disclosure.Client # 8 was admitted into the inpatient non-hospital detoxification level of care on October 10, 2017 and was discharged on October 15, 2017. There was a consent to release information form to a family member signed and dated by the client on October 10, 2017; however, the consent form did not include a purpose for disclosure.Client # 15 was admitted into the inpatient non-hospital rehabilitation level of care on November 19, 2017 and was discharged on December 11, 2017. There was a consent to release information form to a family member signed and dated by the client on November 15, 2017; however, the consent form did not include a purpose for disclosure.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Transition of our paper records to electronic medical records has eliminated the risk of fields in the release forms being missed. All required fields have been made mandatory. Automated chart compliance demonstrates vast improvement. |
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
The facility failed to notify the Department within 3 business days following the unusual incidents listed below, which were discovered during the licensing process. The incident dates and reasons are:1.Ambulance presence requested on October 23, 2017; however, the incident was not reported until October 27, 2017.2.Ambulance presence requested on March 16, 2018; however, the incident was not reported until March 22, 2018.3.Ambulance presence requested on November 26, 2018; however, the incident was not reported until November 30, 2018.4.Ambulance presence requested on August 23, 2018; however, the incident was not reported until August 30, 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that there was a lag in reporting to MLHS event reporting system which is the trigger for the reporting to the Department. Event reporting has been added as an agenda item to the daily patient safety huddle. This daily discussion will permit the timely incident report to the Department.
The quality manager will ensure that this corrective action plan is implemented and monitor event reports and unusual incident submissions. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify an individual's identity, which is to include their name, address and date of birth, prior to the administration of a narcotic agent in two of five applicable client records reviewed.Client # 2 was admitted to the inpatient non-hospital detoxification level of care on October 20, 2019 and was active at the time of the inspection.Client # 6 was admitted to the inpatient non-hospital detoxification level of care on November 14, 2017 and was discharged on 11/19/17These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
It was determined that Intake Department was permitting use of Identification that did not specifically meet Department criteria. Policy has been changed to only permit the following types of identification per licensing alert 01-2018:
Any valid or expired national federal, state or local issued photo identification cards.
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A valid or expired passport.
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A valid or expired student photo ID, which contains the patient's Date of Birth (DOB).
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A photo identification card issued by another licensed NTP.
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A valid or expired check cashing photo identification card.
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A birth certificate and Social Security card.
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A copy of a photo of the patient and a letter directly from another licensed NTP in which the patient was previously enrolled.
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A copy of a photo from a medical record with verification of date of birth.
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A state or federal correctional facility identification card.
In the event an individual is unable to obtain any of the items previously listed, the NTP may utilize either method below. An exception from DDAP is not required.
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An NTP may accept any valid or expired photo identification card issued by a national, federal, state or local governmental agency without the patient's DOB in conjunction with a document that contains the patient's DOB (e.g., birth certificate, marriage certificate, a formal signed letter from an agency that provides/provided services to the patient, etc.). Facilities are required to keep copies of any documents used to verify a patient's identity in the patient's record.
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With the written consent from the patient, the NTP may contact the patient's insurer in efforts to verify identification. Information obtained from the insurer must be documented and include the following:
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Name
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DOB
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Gender
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Race
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Ethnicity (If available)
The NTP must maintain within the patient's record, the following:
Admission and Nursing staff will be trained regarding new policy at December departmental meetings.
Nursing Manger and Intake Supervisor will assure corrective action plan is implemented and complete chart audits to monitor compliance. They will report the compliance to the Quality Manger.
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