INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 9, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
The facility failed to ensure that employee #6 received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe. Employee #6 was hired as a counselor on May 22, 2017 and was due to have HIV/AIDS training no later than May 22, 2018. The HIV/AIDS training was completed on July 16, 2018 and the TB/STD training was completed on July 20, 2018.The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Mirmont policy will continue to require staff to complete these trainings within a year of hire. Quarterly meetings with Human Resources and the Office Coordinator will ensure compliance moving forward. Employee # 6 completed HIV/Aids training on 7/16/2018 and TB/STD training on 7/20/2018. |
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.
|
Observations
The facility failed to properly document the type of treatment services the client was to receive on the client's individual treatment plan in six of eight client records reviewed. Client #1 was admitted on May 23, 2018 and was active at the time of inspection. The comprehensive treatment plan was dated June 12, 2018.Client #2 was admitted on August 14, 2018 and was active at the time of the inspection. The comprehensive treatment plan was dated September 24, 2018. Client #3 was admitted on August 9, 2018 and was active at the time of the inspection. The individualized treatment plan was dated August 30, 2018.Client #4 was admitted on June 12, 2018 and was discharged on June 28, 2018. The individualized treatment plan was dated June 26, 2018.Client #7 was admitted on January 18. 2018 and was discharged on April 30, 2018. The individualized treatment plan was dated February 12, 2018.Client #8 was admitted on December 19, 2017 and was discharged on March 15, 2018. The individualized treatment plan was dated January 16, 2018.These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Treatment planning specifically the need to document types of services will be discussed at the 11/29/2018 Substance Use Disorder departmental staff meeting held by the Clinical Supervisor . As well treatment planning will be discussed at the all staff meeting on 12/12/2018 held by the Division Manager. Supplemental training is in the process of being developed with a focus on treatment planning and will be provided to all staff prior to 03/01/2019. This will be tracked in monthly chart audits completed by the clinical supervisor ensuring the frequency and duration of services recommended is documented in the treatment plan. |
711.93(a)(5) LICENSURE Individualized Tx Plan
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:
(5) Individualized drug and alcohol treatment and rehabilitation plan.
|
Observations
The facility failed to document that the individual treatment and rehabilitation plans were developed with the client in four of eight applicable client records.Client #1 was admitted on May 23, 2018 and was active at the time of inspection. The comprehensive treatment plan was dated June 12, 2018 did not contain a client signature.Client #2 was admitted on August 14, 2018 and was active at the time of the inspection. The comprehensive treatment plan was dated September 24, 2018 did not contain a client signature. Client #3 was admitted on August 9, 2018 and was active at the time of the inspection. The individualized treatment plan was dated August 30, 2018 did not contain a client signature.Client #4 was admitted on June 12, 2018 and was discharged on June 28, 2018. The individualized treatment plan was dated June 26, 2018 did not contain a client signature.These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Treatment planning specifically the need to have a Pt involved in the treatment planning process will be discussed at the 11/29 Substance Use Disorder departmental staff meeting held by the Clinical Supervisor. As well it will be discussed at the all staff meeting on 12/12/2018 held by the Division Manager. Supplemental training is in the process of being developed with a focus on treatment planning which will be completed prior to 03/01/2019. This will be tracked in monthly chart audits by the clinical supervisor ensuring the patient is involved in the process of treatment planning. |
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:
|
Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in four of eight client records reviewed. Additionally, the facility two of eight client records had consent to release information forms that were missing elements. Client #1 was admitted on May 23, 2018 and was active at the time of inspection. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information.Client #2 was admitted on August 14, 2018 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information. Client #3 was admitted on August 9, 2018 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information. Additionally, there were four consents to release information forms to a urinalysis lab, a family member, and two insurance providers signed by the witness on November 8, 2018; however, there was no client signature on the forms.Client #4 was admitted on June 12, 2018 and was discharged on June 28, 2018. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information.Client # 6 was admitted on December 15, 2017 and was discharged on March 15, 2018. There were two consent forms to a primary care provider and a lab signed and dated by the client on December 15, 2017; however, they did not specify the name of the of the person or organization for whom disclosure was being made. The findings were reviewed with facility staff during the licensing inspection.The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in four of eight client records reviewed. Additionally, the facility two of eight client records had consent to release information forms that were missing elements. Client #1 was admitted on May 23, 2018 and was active at the time of inspection. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information.Client #2 was admitted on August 14, 2018 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information. Client #3 was admitted on August 9, 2018 and was active at the time of the inspection. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information. Additionally, there were four consents to release information forms to a urinalysis lab, a family member, and two insurance providers signed by the witness on November 8, 2018; however, there was no client signature on the forms.Client #4 was admitted on June 12, 2018 and was discharged on June 28, 2018. There was documentation of the facility billing the funding source; however, there was no consent form on file prior to the disclosure of information.Client # 6 was admitted on December 15, 2017 and was discharged on March 15, 2018. There were two consent forms to a primary care provider and a lab signed and dated by the client on December 15, 2017; however, they did not specify the name of the of the person or organization for whom disclosure was being made. The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
This issue was rectified and corrected prior to the licensure review as it was caught not long after the 05/01/2018 launch of our electronic medical record. Our present practice is completed by all of our Patient Access staff and a release is obtained for both the medical and behavioral health components of the insurance policy. All active participants will be brought into compliance prior to 01/01/2019 as the Clinical Supervisor and Patient Access Supervisor will review open records for compliance. the Patient Access Supervisor will continue to manage the appropriate and correct releases are done on a regular and consistent basis. |