INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2024 through September 10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mirmont Alcohol Rehabilitation Center d/b/a 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 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the facility's September 2023 through July 2024 fire drill logs, the facility failed to conduct fire drills on different days of the week and on different staffing shifts.
The facility is a residential facility; therefore, their hours of operation are 24 hours per day Sunday through Saturday. Every fire drill conducted during the reviewed period was completed on Monday through Friday. There were no fire drills conducted on Saturdays or Sundays.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Director's responsibilities include scheduling, holding, and documenting fire drills. The Maintenance Director was educated on the requirement for fire drills on different days of the week and on different staffing shifts including Saturday and Sunday. Mirmont Treatment Center is in compliance as of 9/29/2024 when a weekend fire drill was held. The Maintenance Director is responsible to maintain compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of the policy and procedure manual and client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in four of eleven applicable client records reviewed.
The policy and procedure manual stated that the follow-up information call will be completed within 7 days of discharge.
Client #4 was admitted to the inpatient non-hospital detoxification level of care on December 1, 2023 and was discharged on December 3, 2023. The follow-up information call was due to occur no later than December 10, 2023; however, the follow-up contact was completed on December 29, 2023.
Client #5 was admitted to the inpatient non-hospital detoxification level of care on January 24, 2024 and was discharged on January 28, 2024. The follow-up information call was due to occur no later than February 4, 2024; however, the follow-up contact was completed on February 9, 2024.
Client #8 was admitted to the inpatient non-hospital level of care on November 29, 2023 and was discharged on January 4, 2024. The follow-up information call was due to occur no later than January 11, 2024; however, the follow-up contact was completed on January 19, 2024.
Client #12 was admitted to the inpatient non-hospital level of care on May 29, 2024 and was discharged on June 8, 2024. The follow-up information call was due to occur no later than June 15, 2024; however, the follow-up contact was completed on June 27, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Mirmont Alumni Services Coordinator is responsible to complete patient follow-up calls post discharge per Mirmont policy. Policy has been revised to require f/u calls within 30 days of discharge, instead of 7 days. Alumni Coordinator will now run a discharge list weekly to see what patients are due to have a follow-up call completed within 30 days of discharge and documented in the EMR. IT will develop compliance report reflecting date of discharge, discharge program and F/U phone call documentation. Compliance report is expected to be completed by October 30, 2024. Quality Manager will review compliance report with Alumni Coordinator monthly. |
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 document the dated signature of the client on release of information forms in two of fourteen client records reviewed.
Client #2 was admitted to the inpatient non-hospital detoxification level of care on May 13, 2024 and was discharged on May 17, 2024. There were release of information forms to a funding source and a urinalysis laboratory signed by a witness/facility staff on May 14, 2024; however, the dated signature of the client was not documented on both consent forms.
Client #5 was admitted to the inpatient non-hospital detoxification level of care on January 24, 2024 and was discharged on January 28, 2024. There was a release of information form to an emergency contact signed by a witness/facility staff on January 24, 2024; however, the dated signature of the client was not documented on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patient Access Manager developed refresher education regarding the required fields that must be completed on a release of information, including the patient signature. Education also includes requirement that documentation is completed in the EMR when patient signature cannot be obtained (such as signature pad not working). Both patients had the same patient access staff person complete the Releases incorrectly. The Patient Access Manager will meet with the staff member on 10/4/2024 to reinforce the education. In addition, all patient access staff covering Mirmont will receive the same refresher education. Patient Access Manager will continue to perform monthly audits of required documentation and reinforce with staff as appropriate. |
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
Based on a review of the facility's unusual incident report logs, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire, or ambulance personnel.
On June 22, 2024, there was an incident which required the presence of emergency personnel onsite. However, the incident was not reported to the Department until July 2, 2024.
On June 23, 2024, there was an incident which required the presence of emergency personnel onsite. However, the incident was not reported to the Department until July 2, 2024.
This is a repeat citation from the September 7, 2023 annual licensing renewal 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 to complete DDAP reports timely. In this case, the Patient Safety Manager went on vacation and the covering manager failed to complete DDAP reports. This was realized in July of 2024. From that point, all Patient Safety Managers are now included on the daily Mirmont Huddle where safety events are discussed. The Patient Safety Manager (or covering Manager) will now post the number of DDAP reports completed (even if zero) into the Daily Huddle chat. When Patient Safety doesn't document, the huddle leader will contact Patient Safety Department to ensure that DDAP reporting was not missed in error. Although this was corrected in July, I cannot input a date prior to the survey. |