INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12, 2021 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) (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 three of seven client records reviewed. Client # 2 was admitted on August 2, 2021 and was still active at the time of the inspection. The release of information form to another treatment provider was signed and dated by the witness on August 4, 2021, but the form did not document the dated signature of the client. Client # 3 was admitted on July 13, 2021 and was still active at the time of the inspection. The release of information form to a parole officer was signed and dated by the witness on September 7, 2021, but the form did not document the dated signature of the client. Client # 4 was admitted on July 12, 2021 and was discharged on August 17, 2021. The release of information forms to a parole officer and a primary care physician were signed and dated by the witness on July 12, 2021, but the forms did not document the dated signature of the client. This is a repeat citation from the June 14, 2021 licensing inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Supervisor reviewed expectations for original signature and dates with all staff on 10/19/2021 during a weekly supervision. All staff were informed of the need for Pt's to sign any ROIs at the point of admission or come back in to the building to sign additional ROI's as they progress through the Tx process. This will be monitored monthly by the program supervisor via 10 chart audits a month which will be kept on file. Any Pt's with ROI's that are not done correctly currently will have their therapists reach out and invite them to come in to correct the errors. In order to avoid this moving forward the entire program including all staff were informed on 10/13 that in person ROI's are the only acceptable way to complete an ROI for a Pt. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client records reviewed.Client # 5 was admitted on August 10, 2021 and was administratively discharged on August 23, 2021. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A copy of the aftercare plan was mailed USPS to the Patient which clearly documented the type of DC and reason why. Program supervisor met with the program staff on 10/19/2021 for a weekly supervision meeting and reviewed the DDAP regulations and ensured each staff member understood the need for any administratively discharged Pt's to receive a copy of their aftercare plan. this will be monitored moving forward via 10 chart audits a month and all administrative discharges will be facilitated by the direct therapist and supervisor as well. The Pt who did not receive an after care plan in this citation was mailed a copy of their aftercare plan. |