INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document the instruction in the use of fire extinguishers upon employment in one of nine personnel records reviewed.Employee # 1 was hired as the Project Director on May 13, 2019. The fire extinguisher training was not completed until October 23, 2019.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The assignment for training and
instruction of fire equipment will
have a 5 day deadline built into the
computer based program. The office
coordinator will review utilizing
checklist that all new employees
meet this deadline. The office
coordinator will communicate to the
new employee supervisor of any
staff that fail to meet this deadline
allowing for 2 additional days to
meet compliance.
Employee #1 completed training. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to ensure that all personnel, on all shifts, were trained to perform assigned tasks during emergencies in one of nine personnel records reviewed. Employee # 1 was hired as the Project Director on May 13, 2019. Employee # 1's emergency training was not completed until October 23, 2019. Additionally, the facility failed to document, on their fire drill logs, the exit routes used during fire drills conducted from April 2019 to October 2019. These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The assignment for training and
instruction of assigned tasks during
emergencies will have a 5 day
deadline built into the computer
based program. The office coordinator
will review utilizing checklist that all
new employees meet this deadline.
The office coordinator will communicate
to the new employee supervisor of
any staff that fail to meet this
deadline allowing for compliance for
with in a week.
Employee #1 completed training |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to properly document the type of services the client was to receive on the client's individual treatment plan in three of seven client records reviewed. Client # 2 was admitted on February 19, 2019 and was active at the time of inspection. The comprehensive treatment plan was dated April 26, 2019.Client # 4 was admitted on October 9, 2018 and was discharged on April 30, 2019. The comprehensive treatment plan was dated November 8, 2018. Additionally, the comprehensive treatment plan was missing the client signature.Client # 6 was admitted on November 19, 2018 and was discharged on September 30, 2019. The comprehensive treatment plan was dated January 7, 2019. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Staff were instructed on 12/03 during a staff meeting to ensure all Tx plans are developed with the type of services directly referenced in the Tx plan. This will be monitored monthly by the Supervisor through completion of 10 chart audits to ensure follow through by staff. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in three of six applicable client records reviewed.Client # 2 was admitted on February 19, 2019 and was active at the time of inspection. The comprehensive treatment and rehabilitation plan was completed on April 26, 2019 with an update due no later than June 26, 2019; however, the update was not completed until September 29, 2019. Client # 3 was admitted on April 29, 2019 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on April 29, 2019 with an update due no later than June 29, 2019; however, the update was not completed until August 20, 2019.Client # 4 was admitted on October 9, 2018 and was discharged on April 30, 2019. The comprehensive treatment and rehabilitation plan was completed on November 8, 2018 with an update due no later than January 8, 2019; however, the update was not completed until April 30, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were instructed on the appropriate Tx plan time frames during a staff meeting held on 12/03/2019. this will be monitored by the supervisor monthly through the completion of 10 chart audits. |
711.93(a) LICENSURE Complete Client Record
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
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Observations
The facility failed to provide a complete client record in two of seven client records.Client # 4 was admitted on October 9, 2018 and was discharged on April 30, 2019. The record was missing documentation of follow-up information.Client # 6 was admitted on November 19, 2018 and was discharged on September 30, 2019. The record was missing documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff was informed of this DDAP regulation and coaching was provided during the staff meeting on 12/03/2019. This will be monitored by 10 monthly chart audits completed by the supervisor. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed. Client # 4 was admitted on October 9, 2018 and was discharged on April 30, 2019. There was documentation of communication with an attorney on December 6, 2018; however, the consent to release information form to the attorney was not completed until December 12, 2018. Additionally, the consent form to the attorney was missing the witness signature.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The importance of obtaining informed consent prior to releasing information was reviewed with staff during a staff meeting held on 12/03/2019. This will not only be monitored monthly through the completion of 10 chart audits completed by the supervisor ensure through and complete documentation of all consents, but we will also pull monthly reports form the EMR showing data of any consents which are incomplete. As well a planned training on consents directly conveying the message of their need to be complete is planned for the all staff meeting on 12/11/19. |