Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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Observations
Based on a review of personnel records, the facility failed to provide documentation that individual training plans were developed with input from both the employee and the supervisor in one of eight applicable personnel records reviewed.
Employee # 1 was hired as the facility director on January 31, 2019. The individual training plan was signed by the employee on June 26, 2020, but there was no documentation that the plan was developed with input from their supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Electronic signatures will be obtained on training plans in situations where meeting face to face and getting signatures in person is not possible.
The site director is responsible for ensuring that all training plans are reviewed with the supervisor and signed off on by supervisor.
Employee #1 training plan was electronically signed by supervisor on 8/11/2020. |