INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5, 2024 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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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.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of one applicable personnel record reviewed.Employee #9 was hired as patient access staff on January 30, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than January 30, 2024; however, the TB/STD training was not completed as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #9 has accessed the DDAP training website and is currently on a wait list to complete the required TB/STD training. This will be completed by 10/31/24.
Site Manager and/or SUD supervisor have created a master tracking spreadsheet for all new hires listing staff name, staff hire date and all of the required DDAP trainings.
Site Manager and/or SUD supervisor will enter the dates of completed trainings and obtain staff certificates to be added to the master tracking spreadsheet.
Site Manager and/or SUD supervisor will check this spreadsheet weekly to ensure that all staff take trainings as required. Site Manager and/or SUD supervisor will follow up in weekly staff meeting to ensure that all staff have been registered for DDAP trainings upon hire. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff were instructed in the use of the fire extinguisher upon staff employment in five of five applicable personnel records reviewedEmployee #2 was hired as the facility director on February 18, 2024. There was no documentation that the fire extinguisher training was provided as of the date of the inspection.Employee #3 was hired as a clinical supervisor on February 5, 2024. There was no documentation that the fire extinguisher training was provided as of the date of the inspection.Employee #6 was hired as a counselor on December 26, 2023. There was no documentation that the fire extinguisher training was provided as of the date of the inspection.Employee #7 was hired as a counselor on April 15, 2024. There was no documentation that the fire extinguisher training was provided as of the date of the inspection.Employee #8 was hired as a counselor on May 13, 2024. There was no documentation that the fire extinguisher training was provided 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
Site Manager in consultation with HR and QI will have this fire extinguisher training added to all new hires and completed by current employees by 10/31/24.
Site Manager and/or SUD supervisor have created a master tracking spreadsheet that includes the names, hire dates and required DDAP trainings listed. All staff have been added to the spreadsheet as of 9/30/24. Site Manager and/or SUD supervisor will review this spreadsheet weekly in staff meeting to ensure that all staff have completed needed trainings and provided certificates to SUD supervisor for tracking. Information on the spreadsheet will be updated weekly by SUD supervisor.
As of 9/30/24, QI director has provided access to the Site Manager and SUD supervisor to also access the master Mirmont training system to ensure that Site Manager and/or SUD supervisor can search each new hire and be able to print completed trainings for all staff. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure all personnel, on all shifts, were trained to perform assigned tasks during emergencies in five of five applicable personnel records reviewed.Employee #2 was hired as the facility director on February 18, 2024. There was no documentation that emergency preparedness training was provided as of the date of the inspection.Employee #3 was hired as a clinical supervisor on February 5, 2024. There was no documentation that the emergency preparedness training was provided as of the date of the inspection.Employee #6 was hired as a counselor on December 26, 2023. There was no documentation that the emergency preparedness training was provided as of the date of the inspection.Employee #7 was hired as a counselor on April 15, 2024. There was no documentation that the emergency preparedness training was provided as of the date of the inspection.Employee #8 was hired as a counselor on May 13, 2024. There was no documentation that the emergency preparedness training was provided 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
Site Manager in consultation with HR and QI will have all new hires as well as current employees complete emergency preparedness trainings for fire drills during building working hours by 10/30/24. Shifts are 8:30am-5pm and 1p-9pm. Fire drills will be completed monthly by Site Manager and/or SUD supervisor during working hours. Information for all fire drills is tracked in a Life Safety Documentation binder.
Site Manager and/or SUD supervisor have created a master tracking spreadsheet that includes the names, hire dates and required DDAP trainings listed. All staff have been added to the spreadsheet as of 9/30/24.
Site Manager and/or SUD supervisor will review this spreadsheet weekly in staff meeting to ensure that all staff have completed needed trainings and provided certificates to SUD supervisor for tracking. Information on the spreadsheet will be updated weekly by SUD supervisor.
As of 9/30/24, QI director has provided access to the Site Manager and SUD supervisor to also access the master Mirmont training system to ensure that Site Manager and/or SUD supervisor can search each new hire and be able to print completed trainings for all staff. |
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 sixty days in three of five applicable client records reviewed.Client #1 was admitted on December 7, 2023 and was active at the time of the inspection. A treatment plan update was completed on May 7, 2024 and the next update was due no later than July 7, 2024; however, the update was not completed as of the date of the inspection. Client #2 was admitted on March 8, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 8, 2024 and the first update was due no later than May 8, 2024; however, the update was not completed as of the date of the inspection. Client #3 was admitted on May 24, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 10, 2024 and the first update was due no later than August 10, 2024; however, the update was not completed 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
SUD supervisor will run a weekly report in EMR that shows treatment plans that are coming due for update and will review with all staff in weekly group supervision.
Site Manager and/or SUD supervisor continue to complete monthly chart audits of 10 patient charts. SUD supervisor follows up with assigned therapist when a chart deficiency is noted to make needed corrections and then re-reviews to ensure deficiency was corrected.
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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 a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.Client #4 was admitted on December 5, 2023 and was discharged on February 14, 2024. There was no documentation of follow-up information at the time of the inspection. Client #5 was admitted on February 22, 2024 and was discharged on July 2, 2024. There was no documentation of follow-up information at the time of the inspection. Client #7 was admitted on April 10, 2024 and was discharged on June 20, 2024. There was no documentation of follow-up information 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 Mirmont SUD therapists will now be responsible for completing patient follow up calls post discharge per the Mirmont policy. The policy has been revised to require post discharge follow up calls be made within 30 days rather than 7 days. SUD supervisor will run a discharge list weekly to determine which patients need a follow up call in 30 days and document this outreach in the EMR.
IT is in process of creating a compliance report reflecting date of discharge, discharge program and f/u call documentation. Compliance report is expected to be completed by 10/31/24.
SUD supervisor will review this report weekly with all SUD therapists to ensure all calls have been made and documented. |