INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on November 1, 2016 through November 4, 2016 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records on November 1, 2016, it was determined that employee #17, who was hired as a counselor assistant on 05/10/2015 and promoted to a counselor on 08/06/2015, did not meet the educational and experiential requirements to be a counselor. At the time of the inspection, the employee had a Bachelor's degree in Political Science and only 3 months of clinical experience.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Employee #17 has been transferred to a Counselor Assistant position on 11/21/16
Employee #17 will be under the direct observation for 3 months and close supervision the following 9 months by full time clinical supervisor.
2. All new hires and transfers with in facility will be reviewed by Clinical Supervisor and Human Resources for accurate qualifications.
3. The Clinical Supervisor will assure corrective action plan is completed. The Clinical Supervisor will document supervision, cosign notes and provide performance evaluations.
4. Corrective Action Plan is completed as of 11/21/16 with transfer to counselor assistant position.
5. Employee #17 will continue training hours and certification of addiction counseling.
6. Employee#17 will be promoted to Counselor when required hours and certification completed.
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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
Based on the physical plant inspection conducted on November 2, 2016, it was discovered that the facility failed to maintain patient records in locked storage containers at all times. One patient's record was found in an unlocked and unoccupied outpatient counselor's office. Additionally, the room designated as the patient chart room for the inpatient and detoxification levels of care was accessible by staff members who were not authorized access to highly sensitive patient information, as the room houses various medical equipment, office supplies, and a printer/copier/fax machine.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The facility under the supervision of Plant and Quality Directors will have locked cabinets installed in Chart room to secure client records. Chart Room will be limited to staff members with approved access effective 11/28/16 until locked cabinets are installed. Medical equipment will be relocated to the nursing area. Staff with out authorization for chart access will utilize other copiers.
Staff will attend inservice regarding Confidentiality and review of policy and practices at General Staff Meeting 12/27/16.
2. All client records will be secured in locked cabinets when not in use.
Monthly rounds will be done by members of safety and Infection Team assuring confidentiality in compliance and all client records secure.
3. Director of Quality will assure corrective action plan is implemented.
4. Corrective action plan will be completed by 2/2017.
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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 a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in patient #21's chart. Patient #21 was admitted to the detox level of care on October 17, 2016 and discharged to the inpatient level of care on October 24, 2016 and was still an active patient at the time of the inspection. The patient record contained documentation of a facsimile sent on October 17, 2016 to the funding source that contained the patient's specific substances abused, medications for mental health, length of treatment for mental health, medical diagnoses, drug and alcohol treatment history.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The facility will disclose client information with an informed and voluntary consent following the limits established by 4 Pa. Code 255.5. Staff will participate in review of policy of consent and confidentiality on 12/27 during general staff meeting by Director of Quality.
2. The Director of Admissions and Clinical Supervisors will complete monthly chart audits monitoring compliance. These results will be shared with staff and reported to Quality director starting 1/2017.
3. Director of Admissions and Clinical Supervisors are responsible for implementation of corrective action plan.
4. Corrective Action Plan will be completed 12/27.
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