INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 18, 2026 through August 19, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mirmont Treatment Center 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash, garbage and rubbish in non-combustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week. At the time of the inspection, conducted on August 19, 2026 at approximately 11:15 a.m., there was an uncovered thirty cubic-yard dumpster, located behind the kitchen area of the main building. The dumpster contained lawn clippings, broken furniture, housing insulation, sports equipment, and food and drink garbage.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An Exception Request was submitted to DDAP on 8/20/26 indicating the below information:
"Our facility utilizes a 30-yard construction dumpster for the collection of construction debris and bulk waste materials generated through facility maintenance and renovation activities. Due to the size and type of container, a covered dumpster is not commercially available or practical for this use.
We respectfully request an exception for this dumpster because:
1. The container is used exclusively for non-biodegradable waste, including construction materials, bulk debris, and other non-putrescible items.
2. No food waste, garbage, or other organic materials are placed in this dumpster.
3. All food waste and biodegradable garbage are stored separately in covered dumpsters that prevent the penetration of insects and rodents and are removed at least weekly in accordance with regulatory requirements.
4. The construction dumpster does not contain materials that would create odors, attract pests, or present a health hazard to clients, staff, or visitors.
5. Facility staff monitor the dumpster area routinely and maintain the surrounding grounds in a clean and sanitary condition.
We believe this alternative practice fulfills the intent of the regulation by preventing pest attraction and maintaining a safe, sanitary environment while recognizing the practical limitations associated with large construction-debris dumpsters."
In the event the exception request is denied, the EVS director will coordinate with the company to have the 30-yard dumpster removed from the premises in terms of general use for bulk materials. A 30-yard dumpster may be ordered by the EVS director on an as needed basis for construction projects and will be removed once a project concludes. We are still waiting to hear back from DDAP regarding the results of the request (whether it is approved or denied).
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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 release of information forms in two of fourteen client records reviewed.Client # 6 was admitted to the inpatient non-hospital detoxification activity on July 22, 2026 and was discharged on July 27, 2026. A release of information form to a legal service was signed by the client on July 23, 2026; however, there was no purpose of the disclosure documented on the release form. Client # 9 was admitted to the inpatient non-hospital detoxification activity on July 27, 2026 and was still active at the time of the inspection. A release of information form to a legal service was signed by the client on July 23, 2026; however, there was no purpose of the disclosure documented on the release form. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ROIs may be completed by the intake department, nursing department, counseling department.
Client number 9 in this citation is no longer active with Mirmont (he was discharged on August 20) so the ROI cannot be updated.
The current build in the EMR has a hard stop that all sections must be completed, including purpose of disclosure, in order to be successfully signed off by a patient. It was confirmed after meeting with the EMR team on 8/19/26, however, that a staff member may check off "other" on the purpose of disclosure and they are unable to build a hard stop for the text box to be completed to clarify the specifics of "other".
The staff member that filled out the noncompliant ROI was educated during the DDAP survey (on August 19) on the citation and the need to fill out the text box if other is checked off to indicate the specific purpose(s) of disclosure.
The Access Manager, Nurse Manager, and Clinical Supervisors provided education to all staff regarding the need to indicate specific purposes of disclosure if "other" is checked off. This education was provided during staff meetings on: 1) Intake Department Staff Meeting by Access Manager on 8/28/26, 2) Nursing Department email education on 9/11 and will be educated in Nursing Staff Meeting by Nurse Manager on 9/29, 3) Counseling Department Case Conference Meeting by Clinical Supervisors on 8/21/2026.
Quality Manager, Access Manager or designee, and Nurse Manager or designee will perform audits of 3 charts (or more) monthly to ensure ROI compliance and reinforce with staff as appropriate.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure an individual treatment and rehabilitation plan was developed with the client, and in accordance with the facility policy, in five of seven applicable client records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within three days of admission. Client # 8 was admitted to the inpatient non-hospital activity on July 28, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than July 31, 2026; however, the plan was completed on August 1, 2026. Client # 10 was admitted to the inpatient non-hospital activity on July 29, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than August 1, 2026; however, the plan was completed on August 3, 2026. Client # 11 was admitted to the inpatient non-hospital activity on March 21, 2026 and discharged on April 11, 2026. The individual treatment and rehabilitation plan was due to be completed no later than March 24, 2026; however, the plan was completed on March 25, 2026. Client # 13 was admitted to the inpatient non-hospital activity on February 9, 2026 and discharged on February 19, 2026. The individual treatment and rehabilitation plan was due to be completed no later than February 12, 2026; however, the plan was completed on February 13, 2026. Client # 14 was admitted to the inpatient non-hospital activity on June 10, 2026 and discharged on June 27, 2026. The individual treatment and rehabilitation plan was due to be completed no later than June 13, 2026; however, the plan was completed on June 15, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Behavioral Health Therapists are responsible for developing comprehensive treatment plans with oversight from the Clinical Supervisors.
A behavioral health therapist was identified last winter as lacking timely completion of clinical documentation. Despite attempted interventions by leadership and HR, including a performance improvement plan, the behaviors did not improve and the therapist was subsequently terminated on 4/7/2026.
An EMR Report was created and validated in March of 2026 in order to track compliance with timely completion of comprehensive treatment plans. Re-education on this report was provided during the DDAP survey on 8/19/26 by the Quality Manager to the Inpatient Clinical Supervisors. Starting on 8/21/26, this report is now being utilized every weekday to track compliance with comprehensive treatment plan completion. The Clinical Supervisors are running the report and providing feedback to behavioral health therapists in terms of due dates of the comprehensive treatment plans (the report has a 3-day countdown in terms of treatment plan due dates) during case conference meetings which occur daily M-F. |