INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30-May 3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Summit BHC Westfield, LLC d/b/a Mountain Laurel Recovery Center, was found to be not 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The facility failed to document that all counselor assistants received the required supervision.Employee #9 was hired as a counselor assistant on 11/2/18 with a bachelor ' s degree in Psychology; supervision notes were documented for employee #9 but these did not reflect the required weekly direct observation as part of close supervision for the first 6 months. Additionally, employee #8 was hired as a counselor assistant on 3/8/19 with a bachelor ' s degree in Criminal Justice, however there was no documentation of close supervision at the time of the inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure compliance with all required supervision of Counselor assistants. The Clinical Director will provide supervision and direct observation for any Counselor Assistant based upon the requirements set forth in 704.8 and 704.9. The Clinical Director will document the Counselor Assistant Supervision and Direct Observations in a designated "Supervision Log Book." Documentation of Clinical Supervision and Direct Observation will be reviewed by the Project Director at least once monthly during a Supervision Session with the Clinical Director to ensure and maintain compliance. This "Supervision Log Book" will be made ready and available for review as required and requested. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to ensure that the facility was free from danger to health and safety of clients, staff and visitors.*The sidewalk from the residential area to the facility fitness center had uneven pavers in several areas and multiple steps that were not properly attached which created a trip hazard. *The concrete pad outside of the mechanical room in the rear of the residential building was cracked in half and had heaved upward creating a trip hazard.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure that the residential facility grounds are clean, safe, sanitary and in good repair, being free from all hazards. The Facilities Manager will complete the noted repairs needed to the concrete pad outside of the mechanical room, as well as the sidewalk steps leading to the facility's gym. The Facilities Manager will complete monthly checks of the interior and exterior of the facility to ensure compliance. The Facilities Manager will submit completed checks to the Projector Director, who will review them quarterly at the Quarterly Quality Meeting, "Committee of the Whole." Facility staff will assist in maintaining the safety and cleanliness of the grounds by completing and submitting a work order after they have discovered or been made aware of a safety violation or concern. The Facilities Manager will utilize the work orders to correct the issues noted. |
709.28 (c) 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.
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Observations
The facility failed to document a valid consent to release information for clients #3-14. The facility consent template states that the facility is authorized by the consent to obtain information from the person or agency. Additionally, the facility form entitled " Your Information. Your Rights. Our Responsibility " states the facility can deny requests made by the resident to limit the information released and that for " certain health information " the resident may decide what the facility can release; the form was found in records #1-14.Client #1 was admitted on 04/24/19and was an active client at the time of the licensing inspection. Client #2 was admitted on 04/25/19 and was an active client at the time of the licensing inspection. Client #3 was admitted on 04/26/19and was an active client at the time of the licensing inspection. Client #4 was admitted on 01/06/19 and was discharged on 01/14/19.Client #5 was admitted on 02/02/19 and was discharged on 2/9/19.Client #6 was admitted on 03/3/19 and was discharged on 03/10/19.Client #7 was admitted on 01/03/19 and was discharged on 01/13/19.Client #8 was admitted on 04/11/19 and was an active client at the time of the licensing inspection. Client #9 was admitted on 04/01/19 and was an active client at the time of the licensing inspection. Client #10 was admitted on 03/27/19 and was an active client at the time of the licensing inspection. Client #11 was admitted on 04/02/19 and was discharged on 05/02/19.Client #12 was admitted on 02/1/19 and was discharged on 05/01/19.Client #13 was admitted on 04/3/19 and was discharged on 05/3/19.Client #14 was admitted on 04/3/19 and was discharged on 05/3/19.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure compliance in maintaining valid consents for release of information by retraining facility staff on the usage of their data collection system and correct usage of the Release of Information Form. The Release of Information Form and the Notice of Privacy Practices Form will be corrected in accordance with 709.28. Facility staff will be retrained regarding confidentiality and the consent that a client must provide before their information may be released. The retraining of all staff will be documented by a signed acknowledgment that is kept in their individual personnel file. Facility Staff will honor and abide by the consent provided by the Resident served by MLRC. A resident served by MLRC will not be required to offer any information that they do not willingly and freely consent to providing. MLRC will correct and redistribute the "Notice of Privacy Practices," referred to as the documented titled "Your Information. Your Rights. Our Responsibility" and ensure that the corrected form is used. MLRC Quality Improvement/Risk Management Coordinator, Clinical Director and Admissions Director will ensure that the corrected document is redistributed to all current clients. The changes made will be addressed with current clients. Upon Admission, a person served by MLRC will be given the form and the information reviewed with them by Admissions Staff. MLRC Admissions Director and QI/Risk Management Coordinator will monitor this to ensure compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluative statement and recommendations based on information gathered in client histories in records #1-7.Client #1 was admitted on 04/24/19and was an active client at the time of the licensing inspection. Client #2 was admitted on 04/25/19 and was an active client at the time of the licensing inspection. Client #3 was admitted on 04/26/19and was an active client at the time of the licensing inspection. Client #4 was admitted on 01/06/19 and was discharged on 01/14/19.Client #5 was admitted on 02/02/19 and was discharged on 2/9/19.Client #6 was admitted on 03/3/19 and was discharged on 03/10/19.Client #7 was admitted on 01/03/19 and was discharged on 01/13/19.This information was discussed with facility staff.
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Plan of Correction
MLRC will ensure that a Counselor documents a clinical evaluative statement after the review of the Psychosocial Evaluation for all clients receiving short-term detoxification services. A Counselor will review the Psychosocial Evaluation and document their clinical evaluative statement and recommendations based upon the information that has been gathered from the client in an Initial Progress Note for the Client. Counselors will document their evaluation and recommendations through the Clinical Documentation System employed by MLRC within 2 business days after the evaluation has occurred. The Clinical Director will monitor for compliance and take corrective action as needed. Audit tools that are used by the Clinical Director and the QI/Risk Management Coordinator will be updated to include the verification that a Counselor completed the Clinical Evaluative Summary through the usage of an Initial Progress Note to ensure completion and compliance. Audits that include these criteria will begin in June, 2019. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluative statement and recommendations based on information gathered in client histories in records #8, 10-14.Client #8 was admitted on 04/11/19 and was an active client at the time of the licensing inspection. Client #10 was admitted on 03/27/19 and was an active client at the time of the licensing inspection. Client #11 was admitted on 04/02/19 and was discharged on 05/02/19.Client #12 was admitted on 02/1/19 and was discharged on 05/01/19.Client #13 was admitted on 04/3/19 and was discharged on 05/3/19.Client #14 was admitted on 04/3/19 and was discharged on 05/3/19.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MLRC will ensure that a Counselor documents a clinical evaluative statement after the review of the Psychosocial Evaluation for all clients receiving residential services. A Counselor will review the Psychosocial Evaluation and document their clinical evaluative statement and recommendations based upon the information that has been gathered from the client in an Initial Progress Note for the Client. Counselors will document their evaluation and recommendations through the Clinical Documentation System employed by MLRC within 2 business days after the evaluation has occurred. The Clinical Director will monitor for compliance and take corrective action as needed. Audit tools that are used by the Clinical Director and the QI/Risk Management Coordinator will be updated to include the verification that a Counselor completed the Clinical Evaluative Summary through the usage of an Initial Progress Note to ensure completion and compliance. Audits that include these criteria will begin in June, 2019. |