INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on June 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Mirmont Alcohol Rehabilitation Center d/b/a Mirmont Outpatient Services 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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in five of seven client records reviewed.
Client # 1 was admitted on January 10, 2020 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client and witness on February 4, 2020 and it expired on February 3, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after February 3, 2021. Additionally, the release of information form to the laboratory was signed by the client and witness on February 4, 2020 and it expired on February 3, 2021. There was evidence of disclosures to the laboratory after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after February 3, 2021.
Client # 2 was admitted on March 29, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 4 was admitted on September 14, 2020 and was discharged on January 14, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted on April 1, 2021 and was discharged on May 10, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 6 was admitted on March 25, 2020 and was discharged on June 30, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the COVID 19 Pandemic informed and voluntary consent was obtained verbally as the staff worked remote to ensure the safety of the clients we were providing supports to. As a result of the decreasing COVID number's in the area Effective 07/05/21 all initial evaluations will be done on site and all informed and voluntary consent will be signed in person at that time ensuring this issue is addressed and does not continue. Outreach to active Pt's is underway to invite them into the office to sign informed voluntary consent as needed for any previous digital signatures. As well this will be monitored through 10 monthly chart audits to ensure on going compliance which will be completed by the Substance Use Disorder Supervisor. |
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 four of seven client records reviewed.
Client # 2 was admitted on March 29, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, a laboratory and an emergency contact were signed and dated by the witness on April 13, 2020, but none of the forms documented the dated signature of the client. Additionally, the release of information forms to the funding source and a laboratory were signed and dated by the witness on June 2, 2020, but none of the forms documented the dated signature of the client.
Client # 4 was admitted on September 14, 2020 and was discharged on January 14, 2021. The release of information forms to a laboratory, an emergency contact, a parole officer, and the funding source were signed and dated by the witness on September 14, 2020, but none of the forms documented the dated signature of the client.
Client # 5 was admitted on April 1, 2021 and was discharged on May 10, 2021. The release of information forms to a laboratory, an emergency contact, a parole officer, and the funding source were signed and dated by the witness on April 1, 2021, but none of the forms documented the dated signature of the client.
Client # 6 was admitted on March 25, 2020 and was discharged on June 30, 2020. The release of information form to another treatment provider was signed and dated by the witness on March 24, 2020, but the form did not document the dated signature of the client. Additionally, the release of information forms to a psychiatrist, the parole officer, the recovery house, the funding source, an emergency contact and a laboratory were signed and dated by the witness on March 25, 2020, but none of the forms documented dated signature of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the COVID 19 Pandemic informed and voluntary consent was obtained verbally as the staff worked remote to ensure the safety of the clients we were providing supports to. As a result of the decreasing COVID number's in the area Effective 07/05/21 all initial evaluations will be done on site and all informed and voluntary consent will be signed in person at that time ensuring this issue is addressed and does not continue. Outreach to active Pt's is underway to invite them into the office to sign informed voluntary consent as needed for any previous digital signatures. As well this will be monitored through 10 monthly chart audits to ensure on going compliance which will be completed by the Substance Use Disorder Supervisor. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete an initial drug-screening urinalysis for each prospective patient in one of four patient records reviewed.
Client # 4 was admitted on September 14, 2020 and was discharged on January 14, 2021. There was no documentation that the initial drug-screening urinalysis was completed in the patient record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the COVID 19 Pandemic initial evaluations were conducted via telehealth as the staff worked remote to ensure the safety of the clients we were providing supports to. All patients were instructed to: come to the office, or go to a lab to provide an initial UDS following the virtual evaluation. Some clients did not comply and received services due to client needs. As a result of the decreasing COVID number's in the area all initial evaluations will be done on site and an initial UDS will be collected in person at that time ensuring this issue is addressed and does not continue. |
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 follow-up information in two of four applicable client records reviewed.
Client # 4 was admitted on September 14, 2020 and was discharged on January 14, 2021. The client record did not document follow-up information as of the date of the inspection.
Client # 5 was admitted on April 1, 2021 and was discharged on May 10, 2021. The client record did not document follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirement of follow up calls was reviewed with all staff during a staff meeting on 06/29/2021. Compliance of staff will be monitored weekly in the form of chart audits completed by the SUD Clinical Supervisor as well as monitored on a daily census form maintained by the SUD Clinical Supervisor ensuring compliance moving forward. |