INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 08-09, 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 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) (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
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 one out seven records reviewed.
Client #3 was admitted to the partial hospitalization level of care on November 27, 2024, and discharged to a lower level of care on December 27, 2024. A release of information form for a referral source was signed and dated November 27, 2024; however, it did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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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 Program 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 Program Manager 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 26 staff meeting.
Program Manager or designee will perform audits of >/=3 charts monthly to ensure ROI compliance and reinforce with staff as appropriate.
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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.
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Observations
Based on the review of partial hospitalization client records, the project failed to provided counseling to a client on a regular and scheduled basis that included and documented individual counseling sessions, at least twice weekly, in three of seven records reviewed.
Client #1 was admitted on December 19, 2024 and was discharged on January 09, 2025. The project only documented one individual counseling session for the week of December 15, 2024 through December 21, 2024. Additionally, there was no documentation that the client had any individual counseling sessions for the weeks of December 22, 2024 through December 28, 2024, and December 29, 2024 through January 04, 2025.
Client #2 was admitted on April 23, 2025 and was discharged on May 13, 2025. The project only documented one individual counseling session for the weeks of April 20, 2025 through April 26, 2025, and April 27, 2025 through May 03, 2025, and May 04, 2025 through May 10, 2025.
Client #3 was admitted on November 27, 2024 and was discharged on December 27, 2024. The project only documented one individual counseling session for the week of November 24, 2024 through November 30, 2024, December 8, 2024 through December 14, 2024, and December 15, 2024 through December 21, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager educated Behavioral Health Therapists (BHTs) on the regulatory requirement for SUD patients to receive 2 individuals weekly in PHP level of care (this education has already been completed).
Meetings occurred between Quality Manager, Patient Access Manager, Epic team (Trainer, Analyst, Clinical Informatics Specialist), and Program Manager and Supervisors. At the conclusion of the meetings it was decided that the BHTs will complete all documentation regarding individual sessions including documenting attempts (i.e. missed visits) to ensure that the 2 weekly individuals are documented for each PHP patient. Full roll-out of education to the BHTs will be completed by 11/1/25.
Program Manager will perform audits of >/=3 charts monthly to ensure compliance of two individuals weekly for all SUD PHP pts and reinforce with staff as appropriate.
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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.
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Observations
Based on a review of outpatient client records, 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 one week of discharge, in four of six records reviewed.
Client #8 was admitted on January 10, 2025 and was discharged on February 25, 2025. The client record did not contain documentation of follow-up information.
Client #9 was admitted on March 28, 2025 and was discharged on June 24, 2025. The client record did not contain documentation of follow-up information.
Client #13 was admitted on April 14, 2025 and discharged on June 24, 2025. The client record did not contain documentation of follow-up information.
Client #14 was admitted on January 10, 2025 and discharged on January 28, 2025. The client record did not contain documentation of follow-up information.
This is a repeat citation from the September 11, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists are responsible to complete and document patient follow-up calls post discharge per Mirmont policy. Quality Manager revised policy to require follow-up calls within 30 days of discharge instead of 7 days. This policy was revised and uploaded to MCN Policy Manager on September 18.
Program Manager educated Behavioral Health Therapists on the regulatory requirement for patients to receive follow up calls within 30 days of discharge at a staff meeting on September 19.
The SUD clinical supervisor or designee will run a discharge list weekly to see what patients are due to have a follow-up call completed within 30 days of discharge and document in the EMR. This process is being developed and should be enacted by 12/1/25.
Program Manager will perform audits of >/=3 charts monthly to ensure compliance and reinforce with staff as appropriate.
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