INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2023 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 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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705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the September 2022 through August 2023 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
Fire drills were conducted on February 24, 2023 at 7:45 am and on March 15, 2023 at 7:15 am; however, the facility's hours of operation are Monday through Thursday from 8am to 9pm and Friday from 8am to 5pm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Office management staff was re-educated on DDAP fire drill expectations to be completed within normal hours of operation on 9/14/23. Office manager to facilitate monthly fire drills ongoing that occur between the hours of 8am and 4pm. Program director will monitor compliance each month. |
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 obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client #5 was admitted on September 22, 2022 and was discharged on December 6, 2022. 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All persons responsible for completing Releases of Information (ROI) have been trained on EMR completion of ROI documents since transition to EPIC system on 10/31/22. Clinical supervisor to review 10 patient charts each month and achieve 100% ROI compliance by 12/26/23. All SUD clinical staff re-educated on ROI completion during 9/18/23 staff meeting. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent to release information form in one of seven client records reviewed.
Client #5 was admitted on September 22, 2022 and was discharged on December 6, 2022. A release of information form was signed and dated by the client on November 2, 2022; however, the release form did not include a person, agency, or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All persons responsible for completing Releases of Information (ROI) have been trained on EMR completion of ROI documents since transition to EPIC system on 10/31/22. Clinical supervisor to review 10 patient charts each month and achieve 100% ROI compliance by 12/26/23. All SUD clinical staff re-educated on ROI completion during 9/18/23 staff meeting. |