INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 2, 2025 through September 3, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's September 2024 through August 2025 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided showing a fire drill was conducted during the month of June 2025.
This finding was reviewed with the facility during the licensing process.
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Plan of Correction
Mainline Health Public Safety will be scheduling monthly unannounced Fire Drills with The Facility Director.
Mainline Public Safety will be sending a Calander invite to the Facility Director every month to ensure the Fire Drill is scheduled and being held at least once every month.
Once the monthly Fire Drill is completed documentation is completed by Public Safety and the Facility Director and this documentation is put into the Fire Drill logbook for confirmation of the completed Fire Drill at least once per month.
The Facility Director will monitor and audit the Fire Drill logbook every month to ensure that the monthly fire drills are being completed each and every month in order to demonstrate compliance that the facility is conducting unannounced fire drills at least once a month. |
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 document the specific information to be disclosed on release of information forms in two of fourteen client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on August 18, 2025 and was active at the time of inspection. The release of information forms to the funding source and the emergency contact were signed and dated by the client on July 21, 2025; however, both release forms had "other" as the specific information to be disclosed and the corresponding space to indicate what that specific information was had been left blank.
Client # 13 was admitted to the outpatient activity on May 12, 2025 and was discharged on July 23, 2025. The release of information form to the emergency contact was signed and dated by the client on November 25, 2024; however, the release form did not include what the specific information to be disclosed was.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ROIs are completed by the Patient Access department and the Clinical Team.
Education was provided to Mirmont leadership by Main Line Health Legal Department (Associate General Counsel) on the required components and best methods of completing ROI forms.
The Patient Access Manager educated the Patient Access staff on best practices for ROI completion based on legal department education. The Patient Access team was also educated on the need to verify the specific information on the ROI, and to not leave that specific information blank.
Patient Access will add specific information to be disclosed on release of information forms when applicable.
The Clinical Supervisor provided education to the Clinical staff regarding the need to verify ROI information/specifics prior to disclosures of information.
The clinical staff will add and complete all specific information to be disclosed on release of information forms and not leave spaces blank when the form is checked "other" as specific information to be disclosed.
The Clinical Supervisor will complete the ROI by adding the specific information where the form was left blank for the funding source and the emergency contact for client # 3 by 10/31/2025.
The Facility Director will perform audits of at least three charts monthly to ensure ROI compliance and reinforce with staff as appropriate. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of six applicable client records reviewed.
Client # 11 was admitted to the outpatient activity on October 14, 2024 and was discharged on August 28, 2025. A treatment plan update was completed on November 22, 2024 and the next update was due no later than January 22, 2025; however, the update was not completed until February 12, 2025.
Client # 12 was admitted to the outpatient activity on April 30, 2025 and was discharged on August 8, 2025. The individual treatment plan was completed on April 30, 2025 and the first update was due no later than June 30, 2025; however, the update was not completed until August 8, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will give education on 9/30/2025 to her clinical team that all treatment plans need to be updated every 60 days with or without the client being present.
The Clinical Team will use the resource in the EMR system to show due dates for all treatment plans to ensure the treatment plan updates are done and time stamped in the 60-day time frame.
The Clinical Supervisor will audit 10 charts per month to ensure treatment plan updates are completed every 60 days to demonstrate compliance for the treatment plan standard.
The Facility Director will audit 10 Charts per month to ensure the Clinical Team is meeting the standards in Treatment plans. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include documentation of case consultation notes, in four of four applicable client records reviewed.
Client # 8 was admitted to the outpatient activity on February 24, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 10 was admitted to the outpatient activity on May 27, 2025 and was active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 11 was admitted to the outpatient activity on October 14, 2024 and was discharged on August 28, 2025. There were no case consultation notes documented in the record prior to discharge.
Client # 12 was admitted to the outpatient activity on April 30, 2025 and was discharged on August 8, 2025. There were no case consultation notes documented in the record prior to discharge.
This is a repeat citation from the September 6, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will educate the Clinical team on 10/21/2025 the standard on documenting and completing a case consultation note in all client records.
The Clinical Supervisor will implement a tracking system to ensure a case consultation note will be completed in the EMR system during weekly clinical supervision for all new admissions. The tracking system will be used to document the date the case consultation was completed for the Outpatient census for all active clients. This tracking sheet will be documentation of completed case consultations and a way to keep an organized system to verify all completed case consultations for all admitting clients.
The Clinical Supervisor will keep her documentation of all new admissions that are on her tracking sheet by ensuring a case consultation note has been written in the EMR system for patients in their patient chart.
The Clinical Supervisor will monitor and audit 10 charts per month to ensure that case consultations are being completed and this standard is being met.
The Facility Director will monitor and audit 10 charts per month to ensure the Clinical team is completing case consultation notes in the EMR system, to demonstrate compliance and complete client records.
Client # 8 was active at the time of the survey and is currently active and a case consultation note was completed on 9/11/2025 to meet this standard.
Client # 10 was active at the time of the survey and is currently active and a case consultation note was completed on 9/9/2025 to meet this standard.
Client # 11 was discharged on 10/14/2025, and no case consultation note was written due to the client being discharged however a discharge summary was completed.
Client # 12 was discharged on 8/8/2025, no case consultation note was completed due to discharge however a discharge summery was completed.
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