INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2026 through August 19, 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 Treatment Center 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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709.33 (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 in one of one applicable client records reviewed.Client # 1 was admitted to the partial hospitalization activity on January 13, 2026 and was administratively discharged on January 21, 2026. 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
Administrative discharges are completed by the Behavioral Health Therapists in collaboration/active communication with the Program Manager.
The Program Manager was educated during the DDAP survey on 8/19/26, and again by the Quality Manager on 8/24/26 on the regulatory requirement that in the event of an administrative discharge, client must be notified in writing of a decision to involuntarily terminate treatment, that the notice shall include the reason for the termination, and that the client shall have an opportunity to request reconsideration of a decision terminating treatment. Effective on 8/25/26, the process is that if a Behavioral Health Therapist identifies patient behaviors that may warrant an administrative discharge, the therapist will notify the Program Manager and they will review the case together. If deemed appropriate to perform an administrative discharge, the Behavioral Health Therapist will write the discharge summary note and the Program Manager will complete the regulatory process by ensuring that the patient was notified in writing of the decision to involuntarily terminate treatment, the reason for the termination, and that the client had the opportunity to request an appeal. In the EMR, the Program Manager will document these regulatory requirements were performed during the administrative discharge process. All Behavioral Health Therapists were educated by the Program Manager during their weekly staff meeting on 8/25/26 regarding this process.
Program Manager or designee will perform audits monthly of all administratively discharged clients to ensure compliance with this regulation and reinforce with staff as appropriate.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.Client # 1 was admitted to the partial hospitalization activity on January 13, 2026 and was administratively discharged on January 21, 2026. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative discharges are completed by the Behavioral Health Therapists in collaboration/active communication with the Program Manager.
The Program Manager was educated during the DDAP survey on 8/19/26, and again by the Quality Manager on 8/24/26 on the regulatory requirement that in the event of an administrative discharge, client must be notified in writing of a decision to involuntarily terminate treatment, that the notice shall include the reason for the termination, and that the client shall have an opportunity to request reconsideration of a decision terminating treatment. Effective on 8/25/26, the process is that if a Behavioral Health Therapist identifies patient behaviors that may warrant an administrative discharge, the therapist will notify the Program Manager and they will review the case together. If deemed appropriate to perform an administrative discharge, the Behavioral Health Therapist will write the discharge summary note and the Program Manager will complete the regulatory process by ensuring that the patient was notified in writing of the decision to involuntarily terminate treatment, the reason for the termination, and that the client had the opportunity to request an appeal. In the EMR, the Program Manager will document these regulatory requirements were performed during the administrative discharge process. All Behavioral Health Therapists were educated by the Program Manager during their weekly staff meeting on 8/25/26 regarding this process.
Program Manager or designee will perform audits monthly of all administratively discharged clients to ensure compliance with this regulation and reinforce with staff as appropriate. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's December 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 offsite death of a client.Client # 14 was admitted to the outpatient activity on January 13, 2026 and was discharged on March 13, 2026. The facility was notified of the off-site death of the client on April 10, 2026; however, the death was not reported to the Department at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Safety Manager is responsible for completing DDAP reports timely. In this case, the Patient Safety Manager was unaware that a patient death had occurred of an outpatient.
The Behavioral Health Therapist, that had called and documented the note regarding the patient death, did not notify anyone that this had occurred. The therapist was made aware on 8/21/26 that this is a reportable event and that an internal incident report (RL) needed to be placed. BHT understands without question.
Staff education was completed by the Patient Safety Manager to the Lima Outpatient Department in terms of RL reporting requirements during their weekly team meeting on 9/15/26.
DDAP reporting continues to be reported out on daily safety huddle by the Patient Safety Manager with the Quality Manager and/or Mirmont Huddle Leader verifying DDAP Reports are included in daily huddle and completed to meet the regulatory requirement. The Patient Safety Manager includes education both verbally and in writing (coverage notes) to the patient safety team for anyone who will be covering for her during PTO.
The Patient Safety Manager reported the missed incident into the DDAP system on 9/11/26 and indicated the error that led to the late report.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client and documented per facility policy in five of seven applicable client records reviewed. The facility policy and procedure manual stated the individual treatment and rehabilitation plan is to be completed within five sessions from admission for the partial hospitalization level of care. Client # 1 was admitted to the partial hospitalization activity on January 13, 2026 and was discharged on January 21, 2026. The individual treatment and rehabilitation plan was due to be completed no later than January 20, 2026, upon the conclusion of the fifth session; however, the plan was not completed prior to discharge Client # 2 was admitted to the partial hospitalization activity on July 2, 2026 and was discharged on July 24, 2026. The individual treatment and rehabilitation plan was due to be completed no later than July 10, 2026, upon the conclusion of the fifth session; however, the plan was completed on July 24, 2026. Client # 3 was admitted to the partial hospitalization activity on June 19, 2026 and was discharged on July 2, 2026. The individual treatment and rehabilitation plan was due to be completed no later than June 25, 2026, upon the conclusion of the fifth session; however, the plan was completed on June 30, 2026. Client # 6 was admitted to the partial hospitalization activity on February 26, 2026 and was discharged on March 13, 2026. The individual treatment and rehabilitation plan was due to be completed no later than March 5, 2026, upon the conclusion of the fifth session; however, the plan was completed on March 9, 2026. Client # 7 was admitted to the partial hospitalization activity on April 9, 2026 and was discharged on April 30, 2026. The individual treatment and rehabilitation plan was due to be completed no later than April 15, 2026, upon the conclusion of the fifth session; however, the plan was completed on April 20, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists are responsible for comprehensive treatment plan completion. BHTs were educated on 8/20/2026 regarding the Mirmont Treatment Plan Policy and the need to maintain compliance with the time frames outlined in the policy.
Meetings occurred between Quality Manager, Program Manager, Mirmont OP Director, and EMR Team (analysts, clinical informatics specialist) on building and validating a report that tracks compliance with comprehensive treatment plan completion as well as treatment plan updates. This report is projected to be built and validated for operational use by December 2026. Once the report is available, the new process will include: Program Manager will run the report biweekly (twice a week) and notify clinicians of upcoming deadlines for comprehensive treatment plans.
Program Manager or designee will perform audits of 3 charts (or more) monthly to ensure compliance of comprehensive treatment plan completion for SUD PHP clients and reinforce with staff as appropriate.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that clients received the required counseling services according to the individual treatment and rehabilitation plan in one of three applicable client records reviewed.Client # 5 was admitted to the partial hospitalization activity on March 17, 2026 and was discharged on April 9, 2026. The individual treatment and rehabilitation plan, completed on March 26, 2026, indicated that the client was to receive individual sessions twice per week. The client received did not receive two individual sessions during the week of March 30, 2026. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists (BHTs) are responsible for creating the comprehensive treatment plan and ensuring it is followed, with oversight from the Program Manager.
BHTs were educated on 8/25/26 regarding the requirement to follow the treatment plans as they are written. The Program Manager is performing staff education on best practices for writing and completing treatment plans on 9/22/26.
Program Manager or designee will perform audits of 3 charts (or more) monthly to ensure treatment plans are being followed 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 review of client records, the facility failed to ensure counseling was provided to a client on a regular and scheduled basis, specifically individual counseling at least twice weekly for clients in the partial hospitalization activity, in six of six applicable client records reviewed. Client # 2 was admitted to the partial hospitalization activity on July 2, 2026 and was discharged on July 24, 2026. There were no individual sessions documented in the client record during the week of July 5, 2026. Client # 3 was admitted to the partial hospitalization activity on June 19, 2026 and was discharged on July 2, 2026. There were no individual sessions documented in the client record during the week of June 21, 2026. Client # 4 was admitted to the partial hospitalization activity on April 13, 2026 and was discharged on May 1, 2026. There were no individual sessions documented in the client record during the week of April 19, 2026. Client # 5 was admitted to the partial hospitalization activity on March 17, 2026 and was discharged on April 9, 2026. There were no individual sessions documented in the client record during the week of March 29, 2026. Client # 6 was admitted to the partial hospitalization activity on February 26, 2026 and was discharged on March 13, 2026. There were no individual sessions documented in the client record during the week of March 1, 2026. Client # 7 was admitted to the partial hospitalization activity on April 9, 2026 and was discharged on April 30, 2026. There was only one individual session documented in the client record during the week of April 12, 2026.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists (BHTs) are responsible for documenting individual sessions, or reasons for a missed individual session. BHTs were educated on 8/25/26 regarding the regulatory requirement that SUD PHP patients must receive individual counseling at least twice weekly.
Meetings occurred between Quality Manager, Program Manager, Mirmont OP Director, and EMR team (analysts and clinical informatics specialist) regarding this regulatory requirement and improved methods to document missed individual sessions.
Changes to the EMR build were enacted to make it easier for staff to document if a patient is not seen for group or individual outpatient (PHP/IOP/OP) sessions. Attendance drop-down was added to OP group notes and an absence note with drop-down options for patient not attending sessions was added to SUD individual notes. This went live in the EMR on 8/25/2026. The Clinical Informatics Specialist created a staff education video on these new EMR changes which was provided to all outpatient staff via email communication on 9/10/2026.
A process was developed by Program Manager and Access Manager that if a patient access team employee cancels a patient's appointment, they will notify the Behavioral Health Therapist who will then write a note in the EMR indicating a reason that the patient missed a group and/or individual session that day to ensure compliance with the requirement of 2 weekly individuals for SUD PHP patients. All behavioral health therapists and patient access staff were educated in this process during a weekly staff meeting on 8/25/26.
Program Manager or designee will perform audits of 3 charts (or more) monthly to ensure compliance of two weekly individual sessions for SUD PHP clients and reinforce with staff as appropriate.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in one of one applicable client records reviewed. Client # 8 was admitted to the outpatient activity on April 9, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 17, 2026 and the first update was due no later than June 17, 2026; however, the update was not completed until June 29, 2026. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists are responsible for treatment plan update completion. BHTs were educated on 8/20/2026 regarding the Mirmont Treatment Plan Policy and the need to maintain compliance with the time frames outlined in the policy and regulations.
Meetings occurred between Quality Manager, Program Manager, Mirmont OP Director, and EMR Team (analysts, clinical informatics specialist) on building and validating a report that tracks compliance with comprehensive treatment plan completion as well as treatment plan updates. This report is projected to be built and validated for operational use by December 2026. Once the report is available, the new process will include: Program Manager will run the report biweekly (twice a week) and notify clinicians of upcoming deadlines for treatment plan updates.
Program Manager or designee will perform audits of 3 charts (or more) monthly to ensure compliance of treatment plan update completion for SUD clients and reinforce with staff as appropriate.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided to the clients according to the individual treatment and rehabilitation plan in two of five applicable client records reviewed.Client # 8 was admitted to the outpatient activity on April 9, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on April 17, 2026, indicated the client was to receive two to four individual sessions per month. There was only one individual session documented each month during the months of May 2026 and June 2026. Client # 10 was admitted to the outpatient activity on May 27, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on June 26, 2026, indicated the client was to receive three group counseling sessions per week. There were less than three group counseling sessions documented per week during each of the weeks of June 28, 2026 through the week of August 22, 2026. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists (BHTs) are responsible for creating the comprehensive treatment plan and ensuring it is followed, with oversight from the Program Manager.
BHTs were educated on 8/25/26 regarding the requirement to follow the treatment plans as they are written. The Program Manager is performing staff education on best practices for writing and completing treatment plans on 9/22/26.
Program Manager or designee will perform audits of 3 charts (or more) monthly to ensure treatment plans are being followed and reinforce with staff as appropriate.
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