INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 2, an abbreviated on-site inspection, conducted on June 10, 2021 through June 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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) 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 seven of fourteen client records reviewed.Client # 5 was admitted on September 24, 2020 and was discharged on August 14, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.Client # 6 was admitted on April 29, 2020 and was discharged on May 19, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 7 was admitted on June 30, 2020 and was discharged on July 13, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 9 was admitted on July 14, 2020 and was discharged on February 1, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 10 was admitted on September 10, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 11 was admitted on July 13, 2020 and was discharged on November 8, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 13 was admitted on March 18, 2020 and was discharged on August 28, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In-person services will resume on 8/2/21 so each patient will check in with front desk staff and sign consents prior to the start of any treatment.
Clinical Supervisor will audit 10 charts each month to ensure that consents are being completed. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in one of fourteen client records reviewed. Client # 9 was admitted on July 14, 2020 and was discharged on February 1, 2021. The record contained a release of information form to a government agency, signed and dated by the witness on August 19, 2020, that allowed for the release of discharge documents/summary and medication records, which exceeded the limits established by 4 Pa. Code 255.5. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Re-education by Clinical Supervisor and Site Director will take place with all SUD staff in staff group supervision on 7/27/21.
Patient access supervisor will audit 10 charts each month to ensure that releases of information are signed. |
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 eight of fourteen client records reviewed. Client # 2 was admitted on May 21, 2021 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the witness on May 20, 2021, but the form did not document the dated signature of the client. Client # 5 was admitted on September 24, 2020 and was discharged on August 14, 2020. The release of information forms to the funding source, another treatment provider, a laboratory and an emergency contact were signed and dated by the witness on September 24, 2020, but none of the forms documented the dated signature of the client. Client # 6 was admitted on April 29, 2020 and was discharged on May 19, 2020. The release of information form to the funding source was signed and dated by the witness on April 29, 2020, but the form did not document the dated signature of the client. Additionally, the release of information forms to a laboratory and an emergency contact were signed and dated by the witness on May 12, 2020, but none of the forms documented the dated signature of the client. Client # 7 was admitted on June 30, 2020 and was discharged on July 13, 2020. The release of information forms to a laboratory and the funding source were signed and dated by the witness on June 29, 2020, but none of the forms documented the dated signature of the client. Additionally, the release of information form to the funding source was signed and dated by the witness on June 30, 2020, but the form did not document the dated signature of the clientClient # 9 was admitted on July 14, 2020 and was discharged on February 1, 2021. The release of information form to the funding source was signed and dated by the witness on July 9, 2020, but the form did not document the dated signature of the client. Also, release of information forms to government agencies signed and dated by the witness on July 28, 2020 and August 19, 2020, but none of the forms documented dated signature of the client. Additionally, the release of information forms to the funding source, an emergency contact and a laboratory were signed and dated by the witness on August 28, 2020, but none of the forms documented dated signature of the client.Client # 10 was admitted on September 10, 2020 and was still active at the time of the inspection. The release of information forms to the funding source and a laboratory were signed and dated by the witness on November 11, 2020, but none of the forms documented the dated signature of the client. Client # 11 was admitted on July 13, 2020 and was discharged on November 8, 2020. The release of information forms to the funding source and a laboratory were signed and dated by the witness on September 2, 2020, but none of the forms documented the dated signature of the client. Client # 13 was admitted on March 18, 2020 and was discharged on August 28, 2020. The release of information forms to the funding source, a government agency, a laboratory and an emergency contact were signed and dated by the witness on April 29, 2020, but none of the forms documented the dated signature of the client. Additionally, the release of information forms to the funding source, a laboratory and an emergency contact were signed and dated by the witness on May 1, 2020, but none of the forms documented the dated signature of the client. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In-person services will resume on 8/2/21. Each patient coming in for services will need to check in with front desk staff to sign and date all necessary paperwork, including releases and consents prior to the start of treatment.
Clinical supervisor will audit 10 charts each month to ensure that client signature is present. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in one of two applicable client records reviewed. Client # 4 was admitted on February 8, 2021 and was discharged on March 29, 2021. The individual treatment plan was completed on February 12, 2021 and an update was due no later than March 12, 2021; however, there was no update completed prior to discharge. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and Site director will re-educate staff on treatment plan requirements at staff group supervision on 7/27/21.
Clinical supervisor will audit 10 charts each month to ensure treatment plans are completed timely. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity including the name, address and date of birth prior to the administration of an agent in two of four applicable patient records reviewed. Client # 5 was admitted on September 24, 2020 and was discharged on August 14, 2020. There was no documentation that the verification of the patient's identity was completed in the patient record prior to the administration of an agent. Client # 10 was admitted on September 10, 2020 and was still active at the time of the inspection. There was no documentation that the verification of the patient's identity was completed in the patient record prior to the administration of an agent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Form has been created in the Electronic Medical Record to allow for front desk to confirm patient's identification.
Automatic tracking form has been added to the electronic medical record indicating which patients do not have active photo ID on file.
2 cameras have been ordered for use by the front desk to take pictures if patients present without photo ID.
Client #10 was discharged on 6/28/21 due to non-attendance and was provided referrals to other provider. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete an initial drug-screening urinalysis for each prospective patient in one of four patient records reviewed. Client # 9 was admitted on July 14, 2020 and was discharged on February 1, 2021. There was no documentation that an initial drug-screening urinalysis was completed in the patient record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In-person services will return 8/2/21 which will allow staff to obtain urine drug screens for each patient at evaluation.
Clinical supervisor will audit 10 charts each month to ensure that drug screens are being completed. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in two of four applicable patient records reviewed. Client # 9 was admitted on July 14, 2020 and was discharged on February 1, 2021. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:- May 2020 - 2 hours documented- April 2020 - 1 hour and 30 minutes documented- March 2020 - 2 hours documentedClient # 10 was admitted on September 10, 2020 and was still active at the time of the inspection. The record of service and progress notes showed that less 2.5 hours of psychotherapy per month were provided during the following months:- May 2020 - 1 hour and 30 minutes documented- April 2020 - zero (0) hours documented- March 2020 - zero (0) hours documentedThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and Site Director will re-educate all SUD staff about the requirements for psychotherapy hours at SUD group supervision on 7/27/21. Education will also include reminder about discharging patients in a timely manner.
Clinical supervisor will audit 10 charts per month to ensure that patients are receiving required psychotherapy hours. |
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 review and update treatment and rehabilitation plans at least every sixty days in four of six applicable client records reviewed. Client # 9 was admitted on July 14, 2020 and was discharged on February 1, 2021. The individual treatment plan was completed on July 30, 2020 and an update was due no later than September 30, 2020; however, the update was not completed until March 8, 2021. Client # 10 was admitted on September 10, 2020 and was still active at the time of the inspection. A treatment plan update was completed on November 20, 2020 and another update was due no later than January 20, 2021; however, the update was not completed until March 9, 2021. Client # 12 was admitted on December 13, 2019 and was discharged on July 10, 2020. The individual treatment plan was completed on January 9, 2020 and an update was due no later than March 9, 2020; however, there was no update completed prior to discharge. Client # 13 was admitted on March 18, 2020 and was discharged on August 28, 2020. A treatment plan update was completed on May 1, 2020 and another update was due no later than July 1, 2020; however, the update was not completed until July 25, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and Site Director will re-educate all SUD staff on the treatment plan requirements at SUD group supervision on 7/27/21.
Clinical supervisor will audit 10 charts each month to ensure compliance with treatment planning requirements. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of four applicable client records reviewed.Client # 11 was admitted on July 13, 2020 and was discharged on November 8, 2020. The client record did not document follow-up information as of the date of the inspection.Client # 14 was admitted on February 24, 2020 and was discharged on May 29, 2020. The client record did not document follow-up information as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will re-educate case manager on requirement for follow up documentation by 8/1/21.
Automatic tracker has been added to electronic medical record to alert Clinical Supervisor and Site Director of discharged patients that are due for 7 day follow up. |