INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on June 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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 complete an informed and voluntary consent to release information form prior to the disclosure of information in four of fourteen client records reviewed.
Client # 3 was admitted on March 3, 2021 and was discharged on March 17, 2021. 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.
Client # 7 was admitted on October 21, 2020 and was discharged on November 2, 2020. 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.
Client # 8 was admitted on March 22, 2021 and was still active at the time of the inspection. 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.
Client # 12 was admitted on November 6, 2020 and was discharged on December 23, 2020. 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.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It was determined that record #3 did not have a Consent to Release Information for the funding source. The staff member has been educated to obtain a consent to release information for every disclosure. The Outpatient Program Manager will complete monthly chart audits to assure compliance and results will be reported to the Quality Manager.
Three of the records (#7,#8,#12) did not have an original signature on the Consent to Release Information. It was determined that verbal signatures were obtained for Consents to Release Information during the COVID19 pandemic when treatment occurred via telehealth sessions. Because the positivity rates have returned to "low" (<5%), outpatients are coming onsite for evaluation and the consents to release information are now being signed by the patient at that time. In addition, Mirmont plans to implement a non-episodic for the Mirmont TaxID. This will greatly reduce the number of documents requiring an original patient signature. A long-term solution should this situation occur again, is to obtain a waiver for the federal regulation requiring an original patient signature for the consent to release information.
The active patient listed at the time of the inspection has since been discharged.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of fourteen client records reviewed.
Client # 7 was admitted on October 21, 2020 and was discharged on November 2, 2020. The release of information forms to a recovery house, an emergency contact, an employer, a laboratory, an attorney and a funding source were signed and dated by the witness on October 21, 2020, but none of the forms documented the dated signature of the client.
Client # 12 was admitted on November 6, 2020 and was discharged on December 23, 2020. The release of information forms to a recovery house, an emergency contact, a laboratory, an attorney and a funding source were signed and dated by the witness on November 5, 2020, but none of the forms documented the dated signature of the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
It was determined that verbal signatures were obtained for Consents to Release Information during the COVID19 pandemic when treatment occurred via telehealth sessions. Because the positivity rates have returned to "low" (<5%), outpatients are coming onsite for evaluation and the consents to release information are now being signed by the patient at that time. In addition, Mirmont plans to implement a non-episodic Consent to Release Information form for the Mirmont TaxID. This will greatly reduce the number of documents requiring an original patient signature. A long-term solution should this situation occur again, is to obtain a waiver for the federal regulation requiring an original patient signature for the consent to release information. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including their name, address and date of birth, prior to the administration of an agent in two of three applicable patient records reviewed.
Patient # 3 was admitted on March 3, 2021 and was discharged on March 17, 2021. There was no documentation that the verification of the patient's identity was completed in the client record prior to the administration of an agent.
Patient # 8 was admitted on March 22, 2021 and was still active at the time of the inspection. There was no documentation that the verification of the patient's identity was completed in the client record prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was determined that the Intake Department staff did not verify the identification of the patients. Intake staff will be trained regarding policy to verify patient identity at July departmental meetings. A compliance report is being developed that returns a list of active patients whose identity was not verified either with an appropriate identification document scanned into the electronic medical record or not verified with an insurance company. The Intake Department Manager is responsible to review the compliance report daily and rectify problems promptly. Intake Department Manager will assure corrective action plan is implemented and will complete chart audits to monitor compliance. Intake Department Manager will report compliance to the Quality Manager. Compliance report scheduled to be implemented 7/15/2021.
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