INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9-10, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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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 seven detox client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two of the seven records reviewed.
Client #4 was admitted on November 21, 2024, and discharged November 23, 2024. There was documentation that information was disclosed to the funder on November 21, 2024, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.
Client #12 was admitted to the inpatient level of care on March 25, 2025 and discharged on April 15, 2025. There was documentation that information was disclosed to a family member on April 14, 2025, however, the record did not contain documentation of an informed and voluntary consent from the client for disclosure of information.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ROIs may be completed by the admissions department, intake department, nursing department, counseling department.
The Admissions Manager, Nurse Manager, and Clinical Supervisors provided education to all staff regarding the need to provide informed and voluntary consent for all entities/people that a disclosure of information is planned for. This education was completed in various staff meetings prior to 9/30/25.
For any of the identified clients still actively receiving treatment at Mirmont, they will complete any ROIs needing correction at their next session.
Admissions Manager or designee and Nurse Manager or designee will perform audits of >/=3 charts monthly to ensure ROI compliance and reinforce with staff as appropriate.
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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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. which included the specific information to be disclosed in one of seven records reviewed.
Client #13 was admitted on August 19, 2025, and was still active at the time of the inspection. A release of information form for the emergency contact was signed and dated on August 19, 2025; however, it did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ROIs may be completed by the admissions department, intake department, nursing department, counseling department.
Education was provided to Mirmont Nurse Manager, Clinical Supervisors, Admissions Manager by Main Line Health Legal Department (Associate General Counsel) on the required components and best methods of completing ROI forms. This education was provided on 9/22/25.
The Admissions Manager, Clinical Supervisors, and Nurse Manager educated their staff on best practices for ROI completion based on legal department education. The Admissions Manager, Nurse Manager, and Clinical Supervisors provided education to all staff regarding the need to verify ROI information/specifics prior to disclosures of information. This education was provided in various staff meetings prior to 9/30/25.
For any of the identified clients still actively receiving treatment at Mirmont, they will complete any ROIs needing correction at their next session.
Admissions Manager or designee and Nurse Manager or designee will perform audits of >/=3 charts monthly to ensure ROI compliance and reinforce with staff as appropriate.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the dated signature of the client in one out of seven records reviewed.
Client #1 was admitted to the detox level of care on August 14, 2025, and discharged to a lower level of care on August 21, 2025. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated August 15, 2025, for the emergency contact did not include the dated signature of the client. The facility confirmed disclosure had occurred.
This is a repeat citation from the September 9-10, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ROIs may be completed by the admissions department, intake department, nursing department, counseling department.
Nurse Manager, Admissions Manager, and Clinical Supervisors provided education to all staff regarding the need to verify ROI completion and signature prior to a disclosure of information. This education was provided in various staff meetings prior to 9/30/25.
The Epic build went live 10/6/25 to better indicate to staff in the "Media" section with a new column whether an ROI is "signed/active, revoked, not signed" etc to avoid inadvertent disclosures. All Mirmont staff were be educated in this change on 10/6/25 via email education and Epic tip sheet.
For any of the identified clients still actively receiving treatment at Mirmont, they will complete any ROIs needing correction at their next session.
Admissions Manager or designee and Nurse Manager or designee will perform audits of >/=3 charts monthly to ensure ROI compliance and reinforce with staff as appropriate.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven records reviewed.
Client #1 was admitted to the detox level of care on August 14, 2025, and discharged to a lower level of care on August 21, 2025. A consent form dated August 15, 2025, for the emergency contact, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ROIs may be completed by the admissions department, intake department, nursing department, counseling department.
Education was provided to Mirmont Nurse Manager, Clinical Supervisors, Admissions Manager by Main Line Health Legal Department (Associate General Counsel) on the required components of ROI forms. This education was provided on 9/22/25.
The Nurse Manager, Clinical Supervisors, and Admissions Manager educated their staff on the need to document that a copy of a client consent was offered to the client. This education was provided in various staff meetings prior to 9/30/25. There is already a hard stop built into Epic that prevents the completion of an ROI form without the section checked off that a client was offered a copy of the consent. We believe this citation was on an ROI that was not signed by the client/not official and therefore the hard stop would not have been enacted.
For any of the identified clients still actively receiving treatment at Mirmont, they will complete any ROIs needing correction at their next session.
Admissions Manager or designee and Nurse Manager or designee will perform audits of >/=3 charts monthly to ensure ROI compliance and reinforce with staff as appropriate.
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of administrative documents, the facility failed to inform the Department of an unusual incident within the required three business days following an unusual incident.
It was discovered that the facility had an unusual incident occur on February 02, 2025, that involved a physical assault by a client to a staff member. There was no documentation that the facility reported the incident to the Department within the regulatory three business day timeframe.
This is a repeat citation from the September 06, 2023, and September 09, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Safety Manager is responsible for completing DDAP reports timely. In this case, the Patient Safety Manager was unaware that an assault on a staff member needed to be reported to DDAP (she interpreted the wording "Physical or sexual assault by staff or a client" to mean that physical or sexual assault by a staff member to a client, or assault to a client from another client). She is now aware that this needs to be included as an event type to be reported out on. This information was learned during the DDAP survey on 9/10/25.
DDAP reporting continues to be reported out on daily safety huddle by the Patient Safety Manager with the Quality Manager and/or Mirmont Huddle Leader verifying DDAP Reports are included in daily huddle and completed to meet the regulatory requirement. The Patient Safety Manager included education both verbally and in writing (coverage notes) to the patient safety team for anyone who will be covering for her during PTO. This education was provided by 9/19/25.
The Patient Safety Manager reported the missed incident into the DDAP system on 10/7/25 and indicated the error in not knowing this type of incident (assault on a staff member) was also required to be reported to indicate the late report.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for the facility's failure to inform the Department of an unusual incident within the required three business days was submitted and approved by the Department for the September 06-07, 2023, and September 9-10, 2024, annual licensing inspections. Informing the Department of an unusual incident within the required three business days was again found to be a deficiency in the September 10-11, 2025, licensing inspection.
A plan of correction for the facility ' s failure to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the dated signature of the client was submitted and approved by the Department for the September 9-10, 2024 , annual licensing inspection. Obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the dated signature of the client was again found to be a deficiency in the September 10-11, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Previous processes implemented into Mirmont POCs for DDAP reporting (including incorporating patient safety manager into all daily safety huddles and reporting out on submitted DDAP reports) have been followed. The citation this year was a result of confusion and not being aware that an assault to a staff member also need to be reported to DDAP. The Mirmont Patient Safety Manager was made aware during the survey by the DDAP Surveyor on 9/10/25. This information was communicated out by Mirmont Patient Safety Manager to entire Main Line Health Patient Safety team to ensure everyone is aware, and this event type to be reported was also included in coverage notes (i.e. in the event Mirmont Patient Safety Manager is on vacation) by 9/19/25. The Patient Safety Manager reported the missed incident of staff assault to DDAP on 10/7/25. The Quality Manager and/or Mirmont Huddle Leader continue verify during daily safety huddle that all events are reported appropriately (this overall process has not changed since being implemented from 2024 POC).
Mirmont Inpatient Leaders (i.e. Nurse Manager, Admissions Manager, Clinical Supervisors, Quality Manager) received a refresher education on confidentiality by Mirmont Associate General Counsel on 9/22/25. Mirmont leaders then re-educated their staff in confidentiality regulations and the need to verify ROIs prior to any disclosures of information. This education was provided in various staff meetings prior to 9/30/25. Further, the Epic build went live on 10/6/2025 to clearly indicate in the 'Media' section (where ROIs are found) a column that will say next to an ROI 'revoked' 'active' etc to make it clearer to staff. All Mirmont staff received email education with an Epic tip sheet regarding this change. Chart audits will be completed monthly by Admissions Manager or designee and Nurse Manager or designee to ensure confidentiality law is being followed greater than equal to 3 charts at random will be picked each month. |