INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2017 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 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that employee #6 received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe. Employee #6 was hired as counselor on 11/15/16 and was due to have HIV/AIDS training and TB/STD training no later than 11/15/17. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
1. Employee #6 will attend the first available HIV/AIDS training in the are on January 12, 2018 and TB/STD/Hepatitis training on January 26, 2018.
2.The Site Manager and Clinical Supervisor are responsible for ensuring corrective action plan is implemented.
3. The office coordinator will keep a record of completed and uncompleted mandatory trainings for each staff member. The office coordinator will update this document quarterly and present it to the Site Manager and Clinical Supervisor for review.
4. Upon review of this document the Clinical Supervisor will ensure that staff members are signed up for needed trainings.
5..the deficiency will be corrected by 1/29/18.
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711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of 7 client records, 2 records were missing the proposed type of support services on the comprehensive treatment plan.Client #2 was admitted to the outpatient level of care on 3/9/17 and was an active client at the time of the inspection. The comprehensive treatment plan was signed on 3/23/17.Client #7 was admitted to the outpatient level of care on 12/13/16 and was discharged on 8/26/17. The comprehensive treatment plan was signed on 1/9/17.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.The facility will implement new process for documentation of proposed type of support services on all client comprehensive treatment plans.
2.The Clinical Supervisor will complete chart audits monthly evaluating compliance starting 1/2/2018.
3. The Site Manager and Clinical Supervisor are responsible for ensuring corrective action plan is implemented.
4.The staff will be trained and educated on process standard of documenting proposed type of support services on all treatment plans on 12/19/17.
5. The deficiency will be corrected by 12/29/17. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of 7 client records, 2 client records had treatment plan updates that were missing at the time of the inspection.Client # 5 was admitted to the outpatient level of care on 8/25/16 and was discharged on 3/1/17. A treatment and rehabilitation plan was completed on 12/13/16. An update was due no later than 2/13/17; however, there was no update was completed prior to discharge.Client #7 was admitted to the outpatient level of care on 12/13/16 and was discharged on 8/26/17. The comprehensive treatment and rehabilitation plan update was completed on 1/9/17. An update was due no later than 3/9/17; however, there was no treatment plan update was completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The facility will implement new process for reviewing and updating all client treatment plans at least every 60 days.
2.The Clinical Supervisor will complete chart audits monthly evaluating compliance starting 1/2/18.
3.The Site Manager and Clinical Supervisor are responsible for ensuring corrective action plan is implemented.
4.The staff will be trained and educated on process standard of reviewing and updating treatment plans at least every 60 days on 12/19/17.
5. The deficiency will be corrected by 12/29/17. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
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Observations
Based on the review of 7 client records, 2 records had consent to release forms that were missing required elements.Client # 3 was admitted to the outpatient level of care on 7/5/17 was an active client at the time of the inspection. There were consents to a probation officer, funding source and family member signed and dated on 6/26/17 by the witness; however, none of the consents contained a dated client signature.Client # 5 was admitted to the outpatient level of care on 8/25/16 and was discharged on 3/1/17. There was a consent to release information form to family member signed and dated by the facility staff on 1/26/17; however, it did not contain a dated client signature.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The facility will have clients sign and date voluntary consent forms for all necessary stakeholders upon their admissions appointment.
2.The Clinical Supervisor will complete chart audits monthly evaluating compliance starting 1/2/18.
3. The Clinical Supervisor is responsible for ensuring corrective action plan is implemented by providing psycho-education to staff during their weekly staff meeting. This will take place on 12/19/17.
4. The staff will be trained and educated on obtaining the required elements of client signature and date on all voluntary consent forms on 12/19/17.
5. The aforementioned client will be provided information regarding the deficiency upon their next appointment and new release forms with signatures will be obtained by 12/29/17.
6. The deficiency will be corrected by 12/29/17. |