INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 1, 2026 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:
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's September 2025 through July 2026 fire drill logs, the facility failed to ensure that their written fire drill log included documentation of the exit route used and the amount of time it took for evacuation.
At the time of the inspection, the September 2025 through December 2025 logs were missing which exit route was used and the amount of time it took for evacuation for each fire drill. Additionally, the July 2026 log was missing which exit route was used during the fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Mainline Health Public Safety schedules and completes monthly unannounced fire drills with the Facility Director.
Mainline Health Public Safety completes all documentation for the completed Fire drills. This documentation has been updated and revised to include the exit route and the amount of time it took for evacuation for each fire drill to ensure compliance with fire drill documentation.
The Facility Director will monitor and audit the Fire Drill logbook every month to ensure that the monthly fire drills have included the updated and revised documentation showing the exit route and the amount of time it took for evacuation for each fire drill to demonstrate compliance for fire drill documentation. |
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 one of fourteen client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on January 21, 2026 and was discharged on February 20, 2026. There was documentation of a family counseling session with the client and two of their family members on February 10, 2026; however, there was no client-signed consent to release information form to one of the family members documented in the record prior to the disclosure of information.
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 the Clinical Team.
The Patient Access Team and the Clinical Team were educated on best practices for ROI completion for all necessary parties, including family members if they participate in a client's treatment.
The Clinical Supervisor will provide education to her Clinical Team at group supervision to educate staff on ROIs, including who an ROI needs to be completed for, including family members who have participated in a client's treatment.
The Facility Director will perform audits of at least three charts monthly to ensure ROI compliance and reinforce with staff as appropriate.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on release of information forms in two of fourteen client records reviewed.
Client # 7 was admitted to the partial hospitalization activity on February 12, 2026 and was discharged on March 5, 2026. A release of information form to the emergency contact was signed by the client on February 12, 2026; however, there was no purpose of the disclosure documented on the release form.
Client # 13 was admitted to the outpatient activity on March 5, 2026 and was discharged on April 16, 2026. A release of information form to the emergency contact was signed by the client on February 12, 2026; however, there was no purpose of the disclosure documented on the release form.
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 the Clinical Team.
All staff will be given education on October 13, 2026, by leadership on the required components and best methods of completing ROI forms.
The Patient Access Manager educated the Patient Access staff on September 10, 2026, on best practices for ROI completion including providing checked documentation showing purpose of disclosure on all release forms.
Client number 7 in this citation is no
longer active with Mirmont Exton (he was
discharged on March 5, 2026) so the ROI
cannot be updated.
Client number 13 in this citation is no
longer active with Mirmont Exton (he was
discharged on April 16,2026) so the ROI
cannot be updated.
The Clinical Supervisor provided education to the Clinical staff on September 8,2026 regarding the need to verify ROI information/specifies prior to disclosures of information including checking and completing purpose of the disclosure on all release forms.
The Clinical Supervisor distributed a form to be signed by all of the Clinical team on the education provided on the release forms to verify the understanding of the education regarding documentation of the signed release form with purpose of disclosure.
The Facility Director and the Clinical Supervisor will perform audits on at least three charts monthly to ensure ROI compliance and reinforce with staff as appropriate. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's September 2025 through August 2026 unusual incident logs, the facility failed to file a written unusual incident report with the Department within three days following an event at the facility requiring the presence of police, fire or ambulance personnel.
On May 14, 2026, there was an event at the facility requiring the presence of fire personnel; however, the incident was not reported to the Department as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Site Manager and Public safety Director met to discuss Fire Drill processes and procedures to educate Public Safety Director on DDAP requirements of reporting any incident including the site requiring the presence of police, fire or ambulance personnel.
Education was given to staff at an all-staff meeting on September 8th, 2026, in regard to incident reporting and completing a written unusual incident report with the Department within three days following an event at the facility requiring the presence of police, fire or ambulance personnel.
The Director of patient safety revised the policy around incident reporting and education was given to staff by leadership on reporting all unusual incidents that the facility requires the presence of police, fire, or ambulance personal by submitting an internal RL in the facility system.
The Patient safety manager will submit an incident report to the Department within three days following an event at the facility requiring the presence of police, fire or ambulance personnel.
The Site Manager will monitor all reported incidents and verify with the Manager of patient safety that all reports were submitted within the required three-day regulation by auding the facilities unusual incident logbook. |