INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 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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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 and the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of two applicable personnel records reviewed.Employee #4 was hired as a counselor on December 27, 2021. The HIV/AIDS training should have been completed no later than December 27, 2022; however, there was no documentation of the HIV/AIDS training being done at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Employee #4 attended the HIV/AIDS online training on 10/3/23.
2. The Clinical Supervisor is responsible for ensuring corrective action plans are 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 clinical supervisor for review.
4. Upon review of this document, the clinical supervisor will ensure that staff members are signed up for required trainings.
5. This deficiency was corrected on 10/3/23. |
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. A fire drill was conducted on June 30, 2023 at 7:15am; however, the facility's documented hours of operation are from 9am to 4pm.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Office coordinator was educated on DDAP fire drill standards including monthly fire drills must be conducted during facility hours of operation.
2. Site Manager or Clinical Supervisor will sign off on the monthly fire drill log to ensure the drill is conducted within facility hours |
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 fourteen client records reviewed.Client #4 was admitted on November 17, 2022 and was discharged on December 7, 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
The identified chart with incorrect Release of Information was reviewed during staff meeting in September. Re-education was provided including the proper and timely documentation of Releases of Information as well as completion of all elements on the Release of Information forms. Clinical Supervisor will audit charts monthly and will supervise staff accordingly to ensure compliance going forward. Supervision has occurred with staff responsible for the improper documentation found during the DDAP audit. New Release of Information document types were created in the EMR on 9/15/23 making it easy to see what Releases have been obtained and therefore what Releases still need to be obtained. A monthly compliance report will be developed within the EMR program. Results will be reviewed by Clinical Supervisor with staff found to not be in compliance with the standard.
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709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a client death or serious injury due to trauma, suicide, medication error or unusual circumstance.The facility was notified of an off-site client death on July 8, 2023 and the incident was not reported to the Department within 3 business days. The incident was reported to the Department on July 21, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The identified incident was reviewed with the Patient Safety Specialist that is responsible for reporting to DDAP. It was discovered that the Patient Safety Specialist did not receive the information within the timeframe required to appropriately report to DDAP. A new process has been implemented-staff was informed of the DDAP timeline and will notify the Clinical Supervisor of all unusual events during the weekly staff meetings. Clinical Supervisor will contact Patient Safety Specialist of all events and she will confirm if a report is needed. If a report is required, patient safety specialist will submit all pertinent information data within the required time frame. |