INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 2023 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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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 consent to release information forms in two of fourteen client records reviewed.
Client #5 was admitted to the outpatient level of care on November 16, 2022 and was discharged on December 16, 2022. The release of information form to an emergency contact was signed and dated by the client on October 31, 2022, but the release form failed to document the specific information to be disclosed.
Client #13 was admitted to the partial hospitalization level of care on October 31, 2022 and was discharged on November 15, 2022. The release of information form to an emergency contact was signed and dated by the client on October 31, 2022, but the release form failed to document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The identified chart with incorrect Release of Information was reviewed during the first department meeting upon conclusion of survey, on October 3,2023. Re-education was provided including the proper and timely documentation of Releases of Information as well as completion of all elements on Release of Information forms. Departmental supervisors will audit charts monthly and will supervise staff accordingly to ensure compliance going forward. Supervision has occurred with staff responsible for the improper documentation found during the DDAP audit. A monthly compliance report will be developed within the EMR program. Results will be reviewed by Department Supervisors with staff found to not be in compliance with the standard. Since EPIC launch on 10/31/22, upgrades have been made to the ROI that mandates all sections of the consent form be completed. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in two of fourteen client records reviewed.
Client #5 was admitted to the outpatient level of care on November 16, 2022 and was discharged on December 16, 2022. The release of information form to an emergency contact was signed by the client on October 31, 2022, but the release form failed to document the purpose of the disclosure.
Client #13 was admitted to the partial hospitalization level of care on October 31, 2022 and was discharged on November 15, 2022. The release of information form to an emergency contact was signed by the client on October 31, 2022, but the release form failed to document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The identified chart with incorrect Release of Information was reviewed during the first meeting upon conclusion of survey, on October 3, 2023. Re-education was provided including the proper and timely documentation of Releases of Information as well as completion of all elements on Release of Information forms. Departmental supervisors will audit charts monthly and will supervise staff accordingly to ensure compliance going forward. Since EPIC launch on 10/31/2022, upgrades have been made to ROI making each section required to be completed before finalizing. Supervision has occurred with staff responsible for the improper documentation found during the DDAP audit. A monthly compliance report will be developed within the EMR program. Results will be reviewed by Department Supervisors with staff found to not be in compliance with the standard. |