INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2019 through November 20, 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 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 12 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. |
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 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. Additionally, the facility failed to utilize alternate exit routes during fire drills conducted on December 2017, January 2018, March 2018, and May 2018 through October 2019. The facility used the front door exit only during these drills.
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. |
711.82(c)(2) LICENSURE Type/Frequency of Treatment
711.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to properly document the type of services the client was to receive on the client's individual treatment plan in four of seven client records reviewed.
Client # 6 was admitted to the partial hospitalization level of care on November 4, 2019 and was active at the time of inspection. The comprehensive treatment plan was dated November 4, 2019.
Client # 9 was admitted to the partial hospitalization level of care on September 13, 2019 and was discharged on September 25, 2019. The comprehensive treatment plan was dated September 13, 2019.
Client # 10 was admitted to the partial hospitalization level of care on August 9, 2019 and was discharged on August 26, 2019. The comprehensive treatment plan was dated August 9, 2019.
Client # 11 was admitted to the partial hospitalization level of care on August 30, 2019 and was discharged on September 12, 2019. The comprehensive treatment plan was dated September 3, 2019. Additionally, the comprehensive treatment plan was missing the client signature.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
1.The facility will implement new process for treatment plans for the PHP clients to specifically include "PHP group therapy 5 days per week and individual therapy at least 2 times per week".
2. Clinical supervisor will complete chart audits for PHP clients monthly evaluating compliance starting January 2, 2020.
3. Clinical supervisor is responsible for ensuring corrective action plan is implemented.
4. All staff were trained and educated on the process of treatment plan development to specifically include type and frequency of treatment and rehabilitation services at the staff meeting on 12/3/19.
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711.82(f)(1) LICENSURE Ind Counseling - 2X WK
711.82. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in four of seven client records reviewed in the partial hospitalization activity.
Client # 5 was admitted on November 4, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of:
November 10, 2019 to November 16, 2019
Client # 6 was admitted on November 4, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of:
November 10, 2019 to November 16, 2019
Client # 7 was admitted on November 6, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of:
November 10, 2019 to November 16, 2019
Client # 10 was admitted on August 9, 2019 and was discharged on August 26, 2019. Documentation of two individual sessions per week was not completed for the weeks of:
August 11, 2019 to August 17, 2019
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The facility will implement new process for individual counseling twice per week for all PHP clients.
2. Clinical supervisor will complete chart audits for PHP clients monthly evaluating compliance starting January 2, 2020.
3. Clinical supervisor is responsible for ensuring corrective action plan is implemented.
4. PHP staff were trained and educated on the regulation of twice weekly individual therapy and documentation of individual sessions for all PHP clients at the staff meeting on 12/3/19.
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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
The facility failed to provide treatment plan updates within the regulatory timeframe in two of five applicable client records reviewed.
Client # 12 was admitted to the outpatient level of care on April 1, 2016 and was still active at the time of the inspection. A treatment plan update was completed on November 7, 2017 with an update due no later than January 7, 2018; however, the update was not completed until August 6, 2018.
Client # 14 was admitted to the outpatient level of care on July 1, 2019 and was still active at the time of the inspection. A treatment plan update was completed on September 4, 2019 with an update due no later than November 4, 2019; however, no update was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The facility will review and reinforce the implementation of treatment plan updates every 60 days for Intensive Outpatient and Outpatient programming clients.
2. Clinical supervisor will complete chart audits for IOP and OP clients monthly evaluating compliance starting January 2, 2020.
3.Clinical supervisor is responsible for ensuring corrective action plan is implemented.
4. All staff were trained and educated on the process of treatment plan update development time frames of every 60 days on 12/3/19.
5. Client #14's treatment plan update was completed on 11/20/19.
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711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
The facility failed to provide a complete client record in two of seven client records.
Client # 15 was admitted to the outpatient level of care on July 29, 2019 and was discharged on August 26, 2019. The record was missing documentation of follow-up information.
Client # 17 was admitted to the outpatient level of care on February 25, 2019 and was discharged on July 15, 2019. The record was missing documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.The facility will review and reinforce the regulation standard of care practice of completing client records to include follow up with all discharged clients within 7 days of their discharge from treatment and documenting the follow up contact in the clients' medical record.
2. Clinical supervisor will complete chart audits for discharged clients monthly evaluating compliance starting January 2, 2020.
3.Clinical supervisor is responsible for ensuring corrective action plan is implemented.
4. All staff were trained and educated on the process of discharging clients to include documenting discharge summary and follow up contact with all clients within 7 days of their discharge. Staff were educated on the form in the electronic medical record where documentation of this outreach is to be completed on 12/3/19.
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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
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 # 12 was admitted on April 1, 2016 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, the consent to release information form to the funding source expired January 17, 2018 and the next consent to the funding source was not signed until March 26, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. The facility will at intake have clients sign voluntary consent to release information forms for their funding source and the facility will review current active client charts in January of each year to ensure releases signed by the clients at intake are valid.
2. Clinical supervisor will complete chart audits for clients monthly evaluating compliance starting January 2, 2020.
3.Clinical supervisor is responsible for ensuring corrective action plan is implemented.
4. Patient Access staff were trained and educated on the process of obtaining signed voluntary consent to release information forms for clients' funding source on 12/3/19.
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