INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1. Based on the findings of Part 2, an abbreviated on-site inspection,Summit BHC Westfield, LLC d/b/a Mountain Laurel Recovery Center was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, no deficiencies were identified during this inspection and no plan of correction is required.
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Plan of Correction
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704.8(c) LICENSURE Full Caseload Assignment
704.8. Qualifications for the position of counselor assistant.
(c) In addition to training, assignment of a full caseload shall be contingent upon the supervisor's positive assessment of the counselor assistant's individual skill level.
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Observations
Based on a review of seven personnel records on August 18, 2020, the facility failed to document a supervisor's positive assessment of a counselor assistant's individual skill level prior to the assignment of a full caseload.Employee #7 was hired on July 2, 2020 as a counselor assistant and was assigned a full caseload prior to a supervisor's positive assessment of their individual skill level. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 8/18/2020 inspection and previous approved POC from 09/05/2020 this has been addressed. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the submitted policy and procedures on client's rights on August 18, 2020, the project failed to include ethnicity in the client rights policy.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per 8/18/2020 inspection and previous POC submitted and approved on 09/05/2020 this has been addressed. |