INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document the instruction in the use of fire extinguishers upon employment in 1 of 14 personnel records reviewed.
Employee # 1 was hired as the Project Director on May 13, 2019. The fire extinguisher training was not completed until October 23, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The assignment for training and instruction of fire equipment will have a 5 day deadline built into the computer based program. The office manager will review utilizing checklist that all new employees meet this deadline. The office manager will communicate to the new employee supervisor of any staff that fail to meet this deadline allowing 2 more days to meet standard.
Employee #1 completed training.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to ensure that all personnel, on all shifts, were trained to perform assigned tasks during emergencies in 1 of 14 personnel records reviewed.
Employee # 1 was hired as the Project Director on May 13, 2019. The emergency training was not completed until October 23, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The assignment for training and instruction of assigned tasks during emergencies will have a 5 day deadline built into the computer based program. The office manager will review utilizing checklist that all new employees meet this deadline. The office manager will communicate to the new employee supervisor of any staff that fail to meet this deadline allowing for 2 days to complete and be compliant.
Employee #1 completed training.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 5 of 14 client records reviewed. Additionally, the facility failed to document the specific information to be released on release of information forms in 2 of 14 client records reviewed.
Client # 1 was admitted to the partial hospitalization level of care on October 14, 2019 and was still active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on October 14, 2019, that allowed for the release of the entire client record, which exceeds the limits established by 4 Pa. Code 255.5.
Client # 2 was admitted to the partial hospitalization level of care on October 4, 2019 and was still active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on October 4, 2019, that allowed for the release of discharge documents and summary, medication information, and diagnosis code, which exceeds the limits established by 4 Pa. Code 255.5.
Client # 7 was admitted to the partial hospitalization level of care on December 12, 2017 and was discharged on December 29, 2017. There were two consent to release information forms to other providers, signed and dated by the client on November 14, 2017 and November 27, 2017, that did not list the specific information to be disclosed.
Client # 8 was admitted to the outpatient level of care on October 10, 2019 and was still active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on October 10, 2019, that allowed for the release of history and physical, treatment plans, intake documents, discharge documents and summary, and psychiatric evaluations, which exceed the limits established by 4 Pa. Code 255.5.
Client # 9 was admitted to the outpatient level of care on October 11, 2019 and was still active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client on October 10, 2019, that allowed for the release of the entire client record, which exceeds the limits established by 4 Pa. Code 255.5.
Client # 10 was admitted to the outpatient level of care on October 2, 2019 and was still active at the time of the inspection. There was a consent to release information to the funding source, signed and dated by the client on October 4, 2019, that allowed for the release of the entire client record, which exceeds 4 Pa Code 255.5. Additionally, there was a consent to release information to a government agency, signed and dated by the client on October 9, 2019, that allowed for the release of history and physical, treatment plans, intake documents, discharge documents and summary, psychiatric evaluations, and medication information, which exceeds the limits established by 4 Pa. Code 255.5.
Client # 14 was admitted to the outpatient level of care on January 2, 2018 and was discharged on January 31, 2018. There were consent to release information forms to other providers, signed and dated by the client on November 14, 2017 and November 27, 2017, that did not list the specific information to be disclosed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff education has been completed at departmental meeting November 18th regarding 4 PA. Code 255.5 related to disclosure of client information and the defined 5 elements. Staff were educated in the process of completing each ROI with clear indications of specific information to be released utilizing form selections.
1. Whether the client is or is not in treatment.
2. The prognosis of the client.
3. The nature of the project.
4. A brief description of the progress of the client.
5. A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Policy revised to clearly outline the restrictions of information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials.
disclosure documentation is required.
The electronic form has new mandated fields where
The Clinical supervisor will assure POC is completed. They will conduct chart audits measuring compliance and report findings the Quality Manager and Director of Clinical Services.
All active client consents identified at time of survey for release of information non-compliance have been edited by the therapists with clients assuring compliance of 4 Pa. Code 255.5.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on release of information forms in four of fourteen client records reviewed.
Client #6 was admitted to the partial hospitalization level of care on November 29, 2017 and was discharged on December 22, 2017. The release of information form to a government agency was signed and dated on November 3, 2017. The release of information form to another provider was signed and dated on November 28, 2017. Both forms did not have a purpose of disclosure.
Client #7 was admitted to the partial hospitalization level of care on December 12, 2017 and was discharged on December 29, 2017. The release of information form to another provider was signed and dated on November 14, 2017. The form did not have a purpose of disclosure.
Client #13 was admitted to the outpatient level of care on December 27, 2017 and was discharged on February 2, 2018. The release of information form to a government agency was signed and dated on November 3, 2017. The release of information form to another provider was signed and dated on November 28, 2017. Both forms did not have a purpose of disclosure.
Client #14 was admitted to the outpatient level of care on January 2, 2018 and was discharged on January 31, 2018. The release of information form to another provider was signed and dated on November 14, 2017. The form did not have a purpose of disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Transition of our paper records to electronic medical records has eliminated the risk of fields in the release forms being missed. All required fields have been made mandatory. Automated chart compliance demonstrates vast improvement.
The Quality manager will assure POC is implemented. The Outpatient Supervisor and Director of Clinical Services will review the mandated fields with staff.
The outpatient supervisor will review charts for compliance and report to the Quality manager and Director of Clinical Services monthly. |