INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2011 through November 3, 2011 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.
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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 the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons and volunteers received 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.
The findings include:
On November 1, 2011 the Staffing Requirements Facility Summary Report was reviewed. The facility documented on the SRFSR four employees that were required to have completed the mandatory training as not having completed the required number of hours of training.
The facility failed to provide documentation of the required HIV/AIDS and TB/STD trainings for four of four employees identified on the SRFSR form, specifically, employees # 4, 19, 20, and 21.
Employee # 4 was hired 11/19/04.
Employee # 4 is an addiction counselor.
Six hours of HIV/AIDS training using a Department approved curriculum was to be completed no later than 11/19/05. At the time of review on 11/01/11, the facility lacked documentation that employee # 4 had completed of a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum.
Employee # 19 was hired 1/16/08.
Employee # 19 is a consultant/instructor.
Six hours of HIV/AIDS training, and four hours of TB/STD trainings were to be completed no later than 1/16/10. At the time of review on 11/01/11,the facility lacked documentation that employee # 19 had completed of a minimum of 6 hours of HIV/AIDS training and 4 hours lf TB/STD trainings using a Department approved curriculum.
Employee # 20 was hired 9/26/08.
Employee # 20 is a yoga consultant.
Six hours of HIV/AIDS training, and four hours of TB/STD trainings were's to be completed no later than 9/26/10. At the time of review on 11/01/11,the facility lacked documentation that employee # 20 had completed of a minimum of 6 hours of HIV/AIDS training and 4 hours lf TB/STD trainings using a Department approved curriculum.
HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment, by 9/26/10.
At the time of review on 11/01/11, employee # 20 had not received the HIV/AIDS and TB/STD training.
Employee # 21 was hired 11/01/08.
Employee # 21 is an addiction counselor.
Four hours of TB/STD trainings were's to be completed no later than 11/1/10. At the time of review on 11/01/11,the facility lacked documentation that employee # 21 had completed of a minimum of 4 hours lf TB/STD trainings using a Department approved curriculum.
The findings were reviewed with facility staff during the inspection and during the exit interview.
The facility was not able to provide further documentation.
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Plan of Correction
All non-compliant staff are registered for the next HIV and TB/STD trainings that will be held at Mirmont in January (TB/SDT) and February (HIV). Proof of the completed trainings will be placed in the staff member's training file and will become part of their permanent record and documented on the SRFSR.
Compliance of mandatory trainings for all staff will be monitored by the SG&D Committee. Department Managers will be notified by the Committee Chair of any staff found to be out of compliance. It will be the responsibility of the Department Manager to meet with the staff member to inplement a plan to meet the trining criteria in a timely fasion |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and a review of the Staffing Requirements Facility Summary Report, it was determined that each counselor did not complete the minimum 25 hours of training for the training year.
The findings include:
On November 1, 2011 the training files and the Staffing Requirements Facility Summary Report were reviewed to ensure that each counselor completed at least 25 clock hours of annual training for the 2010 training year.
Four out of seven employees failed to complete at least 25 clock hours of annual training, specifically, employees # 4, 17, and 18..
Employee # 4, a counselor, was hired 11/19/04.
A review of the Staffing Requirements Facility Summary Report and the employees training file provided only 23 hours of training for the 2010 training year.
Employee # 17, a counselor, was hired 08/08/08.
The Staffing Requirements Facility Summary Report, which was completed by the facility on 10/31/11, only documented 14 training hours.
Employee # 18, a counselor, was hired 01/13/08.
The Staffing Requirements Facility Summary Report, which was completed by the facility on 10/31/11, only documented 20 training hours.
The findings were reviewed with facility staff during the inspection and at the exit interview.
The facility could not produce any further documentation.
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Plan of Correction
The Clinincal Director and the Staff Growth & Development Committee will conduct a quarterly audit of all Clinical Staff's training records to ensure compliance with the requred 25 clock hours of annual training.
The results of the audit will be reported at the quarterly Performance Improvement Meeting. Any Clinical Staff who have not met the pro-rated quarterly target (6-7 hours/quarter) will meet with the Clinical Director to develop a written plan for compliance before the end of the calendar year.
The next audit will be presented at the Performance Improvement Meeting January 2012. Any Clinical Staff who did not meet the requirements will meet with the Clinincal Director for a counsleing session and develop s corrective action plan to prevent this issue from occurring again.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during a physical plant inspection, the facility failed to provide residents with individual bars of soap (with labeled soap container.)
The findings include:
A physical plant inspection was conducted on November 3, 2011 at approximately 1:00 PM.
The facility failed to provide residents with individual bars of soap with labeled soap containers in bathroom # 213, 214, 215, 306, 307, 308, 310, 311, 313, 314, 315, and 316.
During the physical plant inspection the performance improvement director and the director of maintenance were informed that the bathrooms had individual bars of soap that were not in labeled soap containers.
During the exit interview the performance improvement director and the director of maintenance disputed the findings. The surveyor showed the physical plant standard to the performance improvement director, in addition, the regulation was read aloud during the exit interview which was attended by the project director, clinical director, improvement performance director, maintenance director, and a human resource representative.
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Plan of Correction
Any client who chooses to use their own individual bar of soap while at Mirmont will be provided with an individually labeled soap container. The use of individually labedled soap containers will be mandatory and will be monitored daily by the housekeeping and clinical staff during routine daily cleaning and room checks. Any soap found not properly stored will be discarded and the client will be provded with another bar of soap in an individually labeled container. |
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 a review of client records, the facility failed to document an informed and voluntary consent which adhered to the applicable regulations and also contained a statement which constitutes a general consent to release client medical records.
The findings include:
On November 1, 2011, thirteen client records were reviewed to ensure that the facility was obtaining informed and voluntary consents in accordance with the requirements specified at 28 Pa. Code 709.28 (c) (2) and/or 42 CFR Part II Subpart C, Subsection 2.31 (b).
Three out of thirteen records reviewed contained consents to release information that failed to adhere to the requirements specified at 28 Pa. Code 709.28 (c) (2) and/or 42 CFR Part II Subpart C, Subsection 2.31 (b), specifically client records # 1, 5 and 6.
Client # 1 was admitted to the program on 9/30/11, and is still an active client.
On 9/30/11 client # 1 signed an Authorization for Release of Information to a client advocate and to a third party payer.
The Authorization for Release of Information documents allowing the release of "any medical records needed to obtain insurance benefits."
This is a general consent to release information.
Client # 5 was admitted to the program on 8/31/11 and discharged on 9/1/11.
On 8/31/11 client # 5 signed an Authorization for Release of Information to a third party payer.
The Authorization for Release of Information documents allowing the release of "any medical records needed to obtain insurance benefits."
This is a general consent to release information.
Client # 6 was admitted to the program on 8/26/11 and discharged on 9/1/11.
On 8/20/11 client # 6 signed an Authorization for Release of Information to a third party payer.
The Authorization for Release of Information documents allowing the release of "any medical records needed to obtain insurance benefits."
This is a general consent to release information.
Documenting the release of "any medical records needed to obtain insurance benefits" constitutes a general consent to release information and does not comply with 28 Pa. Code or 42 CFR in regards to the form of written consent.
A general consent does not rise to the level of an informed and voluntary consent.
The specific form and content of a valid consent as outlined in these laws/regulations must include:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
The performance improvement director confirmed the findings.
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Plan of Correction
At all clinical deprtmental meetings for Demeber, the managers are to review the requiements for all voluntary consents as specified in 28 Pa. Code 709.28 (c) and /or 42 CFR Part II Subpart C, Subsection 2.31 (b).
The PI Department will review charts on a monthly basis to ensure the voluntary consents are in complaince with applicable law and report findings at the quarterly PI meeting. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record which includes follow-up information.
The findings include:
On November 1, 2011, three client records were reviewed for documentation of follow-up information. The facility failed to document follow-up information in three of three client records reviewed.
The performance improvement director stated "we call all discharges within 7 days to see if they made it to their aftercare appointment, or kept their commitment to attend AA/NA, or if leaving in any other manner if they made it to a meeting and do they need any help/assistance."
The written policy and procedure was consistent with the statement made by the performance improvement director.
Client # 12 was admitted to the program on 9/19/11 and discharged on 9/23/11.
A follow-up was due no later than 9/30/11. The facility failed to document that a follow-up had been completed for client #12 as of the date of the licensing inspection.
Client # 13 was admitted to the program on 7/12/11 and discharged on 8/10/11.
A follow-up was due no later than 8/17/11. The facility failed to document that a follow-up had been completed for client #13 as of the date of the licensing inspection.
Client # 14 was admitted to the program on 5/25/11 and discharged on 6/29/11.
A follow-up was due no later than 7/6/11. The facility failed to document that a follow-up had been completed for client #14 as of the date of the licensing inspection.
The performance improvement director confirmed that client # 12, 13, and 14 did not have documentation of follow-up information within 7 days.
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Plan of Correction
The Outpatient Clinical Supervisor held a staff meeting November 17, 2011 and re-educated the staff on the process requirements for the 7-day follow-up policy (all aftercare and continuing care plans for all discharging clients are given to the PI dept. so a follow-up call can be made and documented). This re-education was documented in the staff meeting minutes.
The PI Coordinator will monitor all discharges/month to ensure that all aftercare plans/continuiing care plans are received by the PI department and follow up calls are made within 7 days of discharge. |