INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of eight personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.Employee #4 was hired as a counselor on December 26, 2023 and was still current in that position. Employee #4 was due to have the communicable disease trainings no later than December 26, 2024; however, there was no documentation of the completion of the TB/STD training within the regulatory timeframe as of the date of the inspection.This is a repeat citation from the September 05, 2024, licensing inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee has successfully completed the required DDAP training for TB/STD training and certificate has been received by SUD supervisor.
Site Manager and/or SUD supervisor have created a master tracking spreadsheet for all new hires listing staff name, staff hire date and all of the required DDAP trainings as of 10/20/2025
Site Manager and/or SUD supervisor will enter the dates of completed trainings and obtain staff certificates to be added to the master tracking spreadsheet as of 10/20/25
Site Manager and/or SUD supervisor will check this spreadsheet weekly to ensure that all staff take trainings as required as of 10/20/25.
Site Manager and/or SUD supervisor will follow up in weekly staff meeting to ensure that all staff have been registered for DDAP trainings upon hire as of 10/20/25.
Clinicians will report training dates to SUD supervisor upon registration as of 10/20/25. |
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.
|
Observations
Based on review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the specific information to be disclosed in two out seven records reviewed. Client #10 was admitted on May 21, 2025 and discharged on July 17, 2025. A release of information form to the referral source, was signed and dated on June 2, 2025; however, it did not include the specific information to be disclosed.Client #13 was admitted on December 12, 2024, and discharged on February 13, 2025. A release of information form to county probation, was signed and dated on December 12, 2024; however, it did not include the specific information to be disclosed. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
ROIs are completed by the Patient
Access department and Behavioral
Health/SUD Clinical department.
Education was provided to Mirmont
Patient Access Manager and
Site Manager by Main Line
Health Legal Department (Associate
General Counsel) on the required
components and best methods of
completing ROI forms. This
education was completed on
September 22.
The Patient Access Manager
educated staff on September 23 on
best practices for ROI completion
based on legal department
education. The Site Manager and SUD supervisor provided education to all staff
regarding best practices for ROI
completion and the need to verify
ROI information/specifics prior to
disclosures of information during
September 29 staff meeting.
SUD supervisor and/or designee will
perform audits of >/=3 charts
monthly to ensure ROI compliance
and reinforce with staff as
appropriate. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) 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.
|
Observations
Based on the review of partial hospitalization client records, the project failed to provide counseling on a regular and scheduled basis to include documented individual counseling, at least twice weekly in three out of five records reviewed.Client #2 was admitted on September 4, 2025 and was still active at the time of the inspection. The project only documented one individual counseling session for the weeks of September 7, 2025 through September 13, 2025, and September 14, 2025 through September 20, 2025. Client #3 was admitted on September 10, 2025 and was still active at the time of the inspection. The project only documented one individual counseling session for the week of September 14, 2025 through September 20, 2025. Client #7 was admitted on July 17, 2025 and discharged on July 28, 2025. The project only documented one individual counseling session for the week of July 20, 2025 through July 26, 2025. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Site Manager and/or SUD supervisor have provided re-education to all SUD clinicians in staff meeting dated 9/29/25 regarding regulations for x2 individual sessions each week for SUD patients.
Site Manager and/or SUD supervisor have met with QI director and Epic build team to have individual sessions added to the clinician's schedules in Epic. Schedules will be updated for clinicians by 10/27/25.
Clinicians to document in chart for both individual and group sessions, including documentation for any patient no shows or cancellations for services. SUD supervisor will complete chart audits monthly to ensure regulations are met.
Site Manager and/or SUD supervisor will review in staff supervision weekly ongoing to ensure sessions are held as required.
|
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of partial hospitalization client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow up information to be completed within seven days of discharge, per facility policy, in two of five records reviewed. Client #12 was admitted on September 25, 2024 and was discharged on December 10, 2024. There was no documentation of follow up information in the client record. Client #13 was admitted on December 12, 2024, and was discharged on February 13, 2025. The follow-up information was not documented until February 25, 2025. This is a repeat citation from the September 05, 2024 licensing inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
QI director changed Mirmont policy for PT follow up calls from 7 days to within 30 days after discharge as of 09/29/25.
Site Manager and/or SUD supervisor provided re-education to all SUD clinicians in staff meeting dated 09/29/25 regarding change in policy for discharge follow up calls.
SUD supervisor completes monthly chart audits to ensure regulations are being met.
SUD supervisor reviews discharges at weekly staff meeting with all SUD clinicians. |