INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 6, 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:
|
Plan of Correction
|
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a review of the facility's September 2023 through July 2024 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's hours of operation were posted as Monday through Thursday from 9:00AM to 9:00PM and Friday from 9:00AM to 4:30PM. All the fire drills reviewed were conducted between the hours of 2:15PM and 3:36PM. There were no fire drills conducted during the morning or evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Site Manager's responsibilities include scheduling, holding and documenting fire drills. The Site Manager was educated on the requirement for fire drills on different days of the week and on different staffing shifts including AM, afternoon and PM hours. The Site Manager will hold fire drills at different days and times once a month to be in compliance with this policy. The Site Manager is responsible to maintain compliance |
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.
|
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 case consultation notes, in five of five applicable client records reviewed.
Client #8 was admitted to the outpatient activity on November 3, 2023 and was active at the time of the inspection. There were no case consultation notes documented at the time of the inspection.
Client #10 was admitted to the outpatient activity on March 28, 2024 and was active at the time of the inspection. There were no case consultation notes documented at the time of the inspection.
Client #11 was admitted to the outpatient activity on March 8, 2024 and was active at the time of the inspection. There were no case consultation notes documented at the time of the inspection.
Client #12 was admitted to the outpatient activity on October 11, 2023 and was discharged on March 27, 2024. There were no case consultation notes documented prior to discharge.
Client #13 was admitted to the outpatient activity on February 1, 2024 and was discharged on May 13, 2024. There were no case consultation notes documented prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor re-educated staff on the Mirmont Policy on case consultation documentation requirements at staff meeting on 9/17/24. The Clinical Supervisor and counselors will document a case consultation note in clients' EMR whenever clients are discussed in staff meetings, daily huddle and when collaborating with prescribers and each other. IT will develop a compliance report reflecting date of case consultation note. Compliance Report is expected to be completed by November 29, 2024. Clinical Supervisor will run the report on a monthly basis and will audit 10 charts per month to ensure case consultation documentation is completed every 90 days. |
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.
|
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 four of four applicable client records reviewed.
Client #12 was admitted to the outpatient activity on October 11, 2023 and was discharged on March 27, 2024. There was no follow-up information documented as of the date of the inspection.
Client #13 was admitted to the outpatient activity on February 1, 2024 and was discharged on May 13, 2024. There was no follow-up information documented as of the date of the inspection.
Client #14 was admitted to the outpatient activity on March 12, 2024 and was discharged on June 5, 2024. There was no follow-up information documented as of the date of the inspection.
Client #15 was admitted to the outpatient activity on February 22, 2024 and was discharged on May 20, 2024. There was no follow-up information documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor re-educated staff on the Mirmont Policy of completing patient follow-up calls post discharge at staff meeting on 9/17/24. The policy was revised to require f/u calls within 30 days of discharge instead of 7 days. The Clinical Supervisor and/or the primary therapists are responsible for calling the client and documenting the call in the clients' EMR. The Clinical Supervisor will run a discharge list weekly to see what patients are due to have a follow-up call. IT will develop compliance report reflecting date of discharge and f/u call documentation. Compliance report is expected to be completed by October 30, 2024. The Clinical Supervisor will review compliance report monthly to ensure follow up calls are made and documented. |