INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's January 2023 through December 2023 training year in one of five applicable personnel records reviewed.
Employee #8 was hired as a counselor on January 3, 2017. The personnel record only had documentation that 20 hours of annual training was completed during the period reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, all employees will be required to keep a log of completed training hours-to-date along with copies of required documentation (certificate and evaluation), in addition to turning in documentation to office manager. Direct manager of employee will monitor log quarterly during scheduled supervisions to reinforce timely completion of training hours. Staff were informed of new process for the calendar year of 2025 today, 10/1/24. |
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.
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Observations
Based on a review of the facility's September 2023 through July 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation were posted as Monday, Wednesday, and Friday from 9:00AM to 9:00PM, Tuesday from 9:00AM to 7:30PM and Thursday from 9:00AM to 3:30PM. Every fire drill conducted during the reviewed period was completed at or prior to 2:30PM. There were no fire drills conducted during the facility's evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The two shifts for behavioral health therapists are: 830am-5pm, and 1pm-9pm. Director of Facilities is responsible for conducting monthly fire drills and maintaining log for Mirmont Treatment Center and Mirmont Outpatient Center in Media. Reviewed with facilities director need to conduct fire drills on all shifts, including evening hours.
On 9/27/2024 drill was conducted during the 1pm-9pm shift at 315pm. Discussed with facilities director that an evening fire drill will be planned between 6pm-9pm in the month of October (before 10/31/24).
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of fifteen client records reviewed.
Client #4 was admitted to the partial hospitalization level of care on April 11, 2024 and was discharged on April 26, 2024. There were release of information forms to two funding sources and a urinalysis laboratory that were signed by a witness/facility staff on April 9, 2024; however, the dated signature of the client was not documented on any of the consent forms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Patient Access manager developed a refresher education for employees, which included the required fields needing completing on the release of information, which includes the patient's signature. Education included that if a signature cannot be obtained (due to non-working signature pad or technical error), that the EMR be documented as such to reference the ROI was reviewed with the patient and the reason to why a signature could not be obtained. Patient Access manager to meet with employee on 10/4/24 to review. Education will be provided to all patient access employees who will cover for Mirmont.
Outpatient clinical manager (supervisor/program manager) will include ROIs in regular monthly chart audits and report and deficiencies to patient access manager (if completed by patient access) or provide supervision to clinical staff (if completed by counseling 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 that treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of seven client records reviewed.
Client #8 was admitted to the outpatient activity on December 28, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 31, 2024 and the first update was due no later than March 31, 2024; however, the update was not completed at the time of the inspection.
Client #9 was admitted to the outpatient activity on November 22, 2023 and was active at the time of the inspection. A treatment plan update was completed on February 22, 2024 and the next update was due no later than April 22, 2024; however, the update was completed on May 7, 2024.
Client #10 was admitted to the outpatient activity on January 3, 2024 and was active at the time of the inspection. A treatment plan update was completed on May 28, 2024 and the next update was due no later than July 28, 2024; however, the update was completed on August 27, 2024.
Client #12 was admitted to the outpatient activity on December 27, 2023 and was discharged on June 25, 2024. A treatment plan update was completed on April 9, 2024 and the next update was due no later than June 9, 2024; however, the update was not completed prior to discharge.
Client #13 was admitted to the outpatient activity on January 8, 2024 and was discharged on June 18, 2024. A treatment plan update was completed on March 19, 2024 and the next update was due no later than May 19, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Results of survey reviewed with clinical team on 10/1/24 in team meeting. Program Manager reviewed with all clinicians during meeting the Mirmont Policy on treatment plans; specifically timeliness of completion for comprehensive treatment plans and treatment plan updates. Working with EPIC IT to create a report that pulls patients with both expired and due to expire within 7 days treatment plans. Goal is to have into production no later than 10/30/24. Manager to run report on a weekly basis.
In meantime and on-going, manager/supervisor will continue to complete monthly chart audits which will include review of treatment plans. |
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 four of four applicable client records reviewed.
Client #11 was admitted to the outpatient activity on January 3, 2024 and was discharged on June 4, 2024. There was no follow-up information documented at the time of the inspection.
Client #12 was admitted to the outpatient activity on December 27, 2023 and was discharged on June 25, 2024. There was no follow-up information documented at the time of the inspection.
Client #13 was admitted to the outpatient activity on January 8, 2024 and was discharged on June 18, 2024. There was no follow-up information documented at the time of the inspection.
Client #14 was admitted to the outpatient activity on January 26, 2024 and was discharged on June 4, 2024. There was no follow-up information documented 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 Alumni Coordinator is responsible for completing patient follow-up calls post discharge per the Mirmont Policy. Policy has been revised to require post discharge follow-up calls within 30 days vs 7days. Alumni Coordinator will now run a discharge list weekly to see what patients will need a follow-up in 30 days and document 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 10/30/24. Quality manager will review report monthly with Alumni Coordinator. |