INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2017 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:
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on November 20, 2017 at approximately 12:45 PM., it was observed that the facility failed to ensure the proper ventillation in the male and female bathrooms near the client lounge as the exhaust fans in both bathrooms were inoperable and neither bathroom had a exterior window.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Site Manager has contacted the landlord and a request to have the fans serviced and operational has been made. Both ventilation systems were replaced on 12/07/2017 and are fully operational. Monthly building inspections/walk through will occur with the office coordinator and Site Manager any identified building/compliance concerns will be addressed monthly. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection conducted on November 20, 2017 at approximately 12:45 PM., the facility failed to ensure that all the heaters in the facility were permanently mounted or installed as a space heater was found in the physician's office.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Following the 11/20/2017 inspection the heater was removed from the physician's office by Site Manager and Medical Director. All staff were notified of the rules against having heaters which are not installed as space heaters. This will be followed up with during the monthly staff meeting on 12/13/2017 ensuring everyone on staff is notified. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of client records, 1 record failed to have documentation that the facility informed their female clients of the potential risks to her or her unborn child of continued use of illicit drugs or withdrawal from a narcotic drug prescribed by the program.Client # 2 was admitted on 10/24/16 and was an active client at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Treatment contract has been updated to include: "For female clients, I understand the possible risk to me or my unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment." This brings the treatment consent in line with DDAP regulations. Client #2 signed a new revised consent to treat at their next scheduled appointment on 11/22/2017 correcting the deficiency. |
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
Based on a review of 7 client records, 3 records had treatment plan updates completed after the regulatory timeframe or were missing at the time of the inspection.Client # 1 was admitted on 4/7/17 and was an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 4/25/17. An update was due no later than 6/25/17; however, the update was completed on 7/19/17.Client #4 was admitted on 4/27/17 and was discharged on 9/19/17. A treatment and rehabilitation plan update was completed on 6/13/17. An update was due no later than 8/13/17; however, the update was completed on 9/14/17.Client #5 was admitted on 2/15/17 and was discharged on 8/30/17. A treatment and rehabilitation plan update was completed on 6/5/17. An update was due no later than 8/5/17; however, there was no update completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor completed staff training regarding Tx plans and these identified issues specifically on 11/30/2017. As well Tx plans will be monitored through the course of the year by the Clinical Supervisor as she will pull 2 to review from each staff person (5 currently) totaling 10 Tx plan reviews per month ensuring compliance throughout programing. |
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
Based on the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 record. Additionally, 3 records had consent to release forms that were missing required elements.Client # 2 was admitted on 10/24/16 and was an active client at the time of the inspection. There were consents intended for a primary care physician that were signed and dated by the client on 10/24/16 and 10/24/17; however, they did not contain the purpose for disclosure, items to be disclosed, expiration date, or dated witness signature. Additionally, there was a consent to a government agency signed and dated by the client on 10/24/16; however, it did not include the purpose of the disclosure.Client #3 was admitted on 8/24/17 and was an active client at the time of the inspection. There was a consent to release information form to the funding source signed/dated by the client on 8/24/17 and expired on 8/24/17. There was documentation that the facility had billed the funding source for services provided after 8/24/17; however, there were no additional updated consent forms in the record. Additionally, there was a consent to release information form signed and dated by the client on 8/24/17 on a government agency letterhead that allowed communication, but did not include the specific information to be released.Client # 4 was admitted on 4/27/17 and was discharged on 9/19/17. There were consent to release information forms to the funding source, another treatment provider, a primary care physician and a urinalysis lab signed and dated by the witness on 4/27/17; however, it did not contain a dated client signature.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor completed staff training regarding consents and release of information on 11/30/2017. This will be done again during the month of April in order to ensure consistency among staff. Staff will no longer require individuals to sign a release of information for the PCP when the individual reports not having one. Delaware County releases of information has been updated and staff are aware of the need to include specific information for the purpose of the release. Staff are aware individuals need to sign and date all release forms moving forward. Client #2 was corrected on 11/20 as a PCP release was entered into he chart without the Pt signature that was documents on the ROI that the client denied having a PCP. As well following the training on 11/30/17 all government agency releases were updated to state the purpose of the ROI. Client #3 the error was corrected 11/22/2017 as the therapist had the client sign a corrected ROI with the correct dates. As well following the training on 11/30/17 all government agency releases were updated to state the purpose of the ROI. Client #4 had been discharged from care prior to licensure review and the omission of the date was documented on 11/20/2017 and initialed by the Site Manager. |