INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 5, 2007 through November 8, 2007 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 on December 10, 2007.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the facility failed to make the annual report available to the public within six months of the end of the facility's fiscal year. The notice of availability to the general public was published in the Daily Times on January 25, 2007 for the facility's July 1, 2006 to June 30, 2007 fiscal year.
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Plan of Correction
In previous years, the facility published the annual report after the first of the calendar year. Mirmont will now publish the annual report within six months of the end of the fiscal year.
Mirmont will be in full compliance within six months of the end of the current fiscal year, viz.,6/30/2008.
The CEO will be responsible for ensuring the timely publishing of the annual report. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent with regards to specific information disclosed in three of four client records reviewed, #1, 3 and 4. The release of information to an insurance company exceeded that allowed by 4 Pa. Code 255.5 in client record #1. The release of information to an employer exceeded that allowed by 4 Pa. Code 255.5(a)(6) in client records #3 and 4.
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Plan of Correction
Some staff members failed to follow Mirmont's policy and procedures for the disclosure of information.
The Director of Performance Improvement will conduct an inservice training for admissions staff and other clinical staff to review the policy and procedure for disclosure of client information. An emphasis will be placed on documentation of informed and voluntary consent with regards to specific information disclosed, and on what can be disclosed according to4 PA Code 255.5.
Mimont will be fully compliant by 1/31/08
The Director of Performance Improvement will monitor for ongoing compliance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant tour and a temperature reading of the hot water, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. The hot water registered at 126 degrees Fahrenheit.
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Plan of Correction
The water tested was from a faucet that was in close proximity to the hot water heaters and registered a temperature higher than allowable.
The Director of Facilities will adjust the water temperature on the hot water heaters to ensure that the hot water will not exceed 120 degrees fahrenheit.
Full compliance will be achieved by 12/31/2007.
The Direcor of Facilities will monitor for continued compliance. |
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
Based on a review of personnel records, the facility failed to document the instruction of all staff in the use of fire extinguishers. Fire extinguisher training was missing for four of four interns, # 17, 18, 19 and 20.
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Plan of Correction
The facility was remiss in documenting the instruction of interns in the use of fire extinguishers.
The Director of Human Resources will hold an inservice/training with the orientation team to review the policy and procedure regarding training and documentation on using the fire extinguishers. Those interns who are still active at Mimont will receive fire extinguisher training again and documetation will be placed in their pesonnel files.
In the future, documentation of training for fire extinguisher use will be placed in all new intern personnel files post training.
Full compliance will be achieved by 1/15/08.
The Director of Human Resources will monitor for ongoing compliance. |
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
Based on a review of personnel records, the facility failed to document training for all staff on emergency procedures. Emergency procedure training was missing for four of four interns, # 17, 18, 19 and 20.
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Plan of Correction
The facility failed to document training on emergency procedures for four interns.
The Director of Human Resources will hold an inservice/training for the orientation team to review the policy and procedure for training staff on emergency procedures.
Any interns still active at Mimont will receive training again in emergency procedures and documentation of the training will be placed in their personnel file. All new iterns will be trained in emergency procedures and documentation to that effect will be placed in their files.
Full compliance will be achieved by 1/15/2007.
The Director of Human Resources will monitor for compliance. |
709.62(c)(3)(ii) LICENSURE D & A History
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a complete drug/alcohol history in two of four client records reviewed, #2 and 3. The drug/alcohol histories included conflicting information on the actual substances used and failed to include lengths and patterns of use.
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Plan of Correction
Clinical Director will hold an inservice for the admissions staff and the counselors on thoroughly completing the drug and alcohol history section of the bio-psycho-social, to ensure consistency in documentation.
Compliance will be achieved by January 15, 2007.
The Clinical Supervisor will monitor for ongoing compliance. |
709.62(c)(3)(iii) LICENSURE Personal history
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a complete personal history in three of four client records reviewed, #2, 3 and 4. The family histories included sections that were blank or documented one word answers with no explanation to show insight into the family of origin, employment background, educational background, sexual history or recreational history.
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Plan of Correction
The Clinical Director will conduct an inservice for the admissions and counseling staff on the thorough and effective completion of the bio-psycho-social.
Compliance wil be achieved by January 15, 2007.
The Clinical Director will monitor for ongoing compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in four of four client records reviewed, #1, 2, 3 and 4. Psychosocial evaluations were either client reported data or a listing of one word answers with no clinical assessment or impressions.
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Plan of Correction
Clinical Director will conduct a inservice training for the admissions and counseling staff on thoroughly and effectively completing the bio-psycho-social evaluation.
Compliance will be achieved by January 15,2007.
The Clinical Director will monitor for ongoing compliance. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a complete drug/alcohol history in four of eight client records reviewed, #2, 3, 4 and 5. The drug/alcohol histories included conflicting information on the actual substances used in client records #2 and 3. The drug/alcohol histories failed to include lengths and patterns of use in client records #2, 3, 4 and 5.
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Plan of Correction
The Clinical Director will conduct a inservice training for the admissions and counseling staff on the thorough and effective completion of the bio-psycho-social history and evaluation. Compliance will be achieved by January 15th, 2007.
The Clinical Director will monitor for ongoing compliance. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a complete personal history in four of eight client records reviewed, #1, 2, 3 and 5. The family histories included sections that were blank or documented one word answers with no explanation to show insight into the family of origin in client records #1, 2, 3 and 5. The employment history was blank in client record #6 and was missing information on previous employment in client records #2 and 5.
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Plan of Correction
The Clinical Director will conduct an inservice/training with the admissions and counseling staff on the thorough and effective completion of the bio-psycho-social history and evaluation.
Compliance will be complete by January 15th, 2007.
The Clinical Diector will monitor for ongoing compliance.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in five of eight client records reviewed, #1, 2, 3, 6 and 8. Psychosocial evaluations contained historical information rather than evaluative information in four client records #2, 3, 6 and 8. Negative factors that might inhibit treatment were missing in three records, #1, 2 and 3. Psychosocial evaluations included a listing of one word answers with no clinical explanation or impressions in client records 1, 2 and 3.
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Plan of Correction
The Clinical Director will conduct an inservice/training with the admissions and counseling staff on the thorough and effective completion of the bio-pshcyo-social history and evaluation.
Compliance will be achieved by January 15th, 2007.
The Clinical Director will monitor for ongoing compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a treatment plan update in two of five client records reviewed, #4 and 7. Treatment plan updates were missing.
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Plan of Correction
The Clinical Director will conduct an inservice/ training with the counseling staff to review the DDAP standards and Mimont's policy and procedures on treatment plan updates.
Compliance will be achieved by January 15th, 2007.
The Clinical Director will monitor for compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a complete drug/alcohol history in seven of eleven client records reviewed, #2, 4, 6, 7, 9, 10 and 11. The drug/alcohol histories failed to include lengths and patterns of use.
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Plan of Correction
The Clinical Director will conduct an inservice/training with the admisswions and counseling staff on a thorough and effective completion of the bio-psycho-social history and evaluation.
Compliance will be achieved by january 15th, 2007.
The Clinical Director will monitor for ongoing compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a complete personal history in seven of eleven client records reviewed, #2, 3, 4, 7, 8, 9 and 10. The family histories included one word answers with no explanation to show insight into the family of origin in client records #2, 7, 8, 9 and 10. The employment section did not give a history in client records #3, 4 and 7. It included current employment, but was missing previous employment information. The education section was missing educational information in client record #3.
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Plan of Correction
The Clinical Director will conduct an inservice/training with the admissions and counseling staff on the thorough and effective completion of the bio-psycho-social history and evaluation.
Compliance will be achieved by january 15th, 2007.
Clinical Director will monitor for ongoing complaince. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in seven of eleven client records reviewed, #2, 3, 6, 7, 8, 9 and 11. Psychosocial evaluations contained historical information rather than an assessment of the client in five records, #2, 3, 8, 9 and 11. Coping mechanisms were missing in two records #7 and 11. Psychosocial evaluations consisted of a listing of one word answers with no clinical explanation or impressions in five records #2, 6, 7, 8 and 11.
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Plan of Correction
The Clinical Director will conduct an inservice/training with the admissions and counseling staff on a thorough and effective completion of the bio-psycho-social history and evaluation.
Compliance will be achieved by January 15th, 2007.
The Clinical Director will monitor for ongoing compliance. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 on a review of client records and the facility's policies and procedures, the facility failed to develop individual treatment plans in a timely manner. As per facility policy, treatment plans were developed late in six of eleven client records reviewed, #4, 7, 8, 9, 10 and 11.
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Plan of Correction
The Clinical Director will hold and inservice to review the Policy and Procedures for timely development of treatment plans.
Compliance will be achieved by january 15th, 2007.
The Clinical Director will monitor for ongoing compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to develop aftercare plans in three of three client records reviewed, #9, 10 and 11.
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Plan of Correction
The Clinical Director will conduct an inservice /training with the counselors to review the DDAP standards and Mimont's policies and procedures regarding completion of aftercare plans.
Compliance will be achieved by January 31st,2007.
The Clinical Director will monitor for ongoing compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a discharge summary in two of six client records reviewed, #7 and 8. The reason for treatment was missing on the discharge summary in one of six client records reviewed, #9.
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Plan of Correction
The Clinical Director will conduct an inservice/training with the counselors on completing a thorough and clinically sound discharge summary.
Compliance will be achieved by January 31st,2007.
The Clinical Director will monitor for ongoing compliance. |
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 and the facility's policies and procedures, the facility failed to document follow-up information in six of six client records reviewed, #6, 7, 8, 9, 10 and 11.
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Plan of Correction
The Director of Performance Improvement will conduct an investigation to find out why the six client records did not have follow-up information. The Director of Performance Improvement will hold an inservice for the follow-up staff and review the policy and procedures for completing and documenting follow-up information.
Compliance will be achieved by January 15th, 2007.
The Director of Performance Improvement will monitor for ongoing compliance. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and staff interview, the facility failed to document monthly meetings between the clinical supervisor and their supervisor in two of two staff records reviewed, #2 and 5.
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Plan of Correction
The CEO will hold monthly supervision sessions with the clinical supervisors and document the minutes of the meetings. The documentation will be submitted to HR for their personnel files.
Compliance to begin by December 31st, 2007.
Ongoing compliance will be monitored by the Director of Performance Improvement. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of personnel records and client records, the facility failed to ensure that counselor assistants (interns) were being supervised by a clinical supervisor or counselor. The facility has four interns who were being supervised by counselor assistants.
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Plan of Correction
The clinical director will meet with the clinical supervisors and counselors and hold an inservice to review the DDAP standards for staffing and supervision. All counselor assistants will be supervised by the clinical supervisors or a counselor. Interns will also be supervised by the a clinical supervisor or a counselor.
Compliance will be achieved by January 1st, 2008.
The clinical dirtector will monitor for ongoing compliance. |