INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. Part 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. Part 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 1, an abbreviated off-site inspection, conducted on August 18, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, Mountain Laurel Recovery 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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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
MLRC will ensure that all Counselor Assistants will have a positive assessment of their individual skill level before carrying a full caseload. This assessment will be completed by the Clinical Director and reviewed with the Counselor Assistant prior to them carrying a full caseload. Copies of the Counselor Assistant positive assessment will be kept in the Clinical Supervision Log and the Counselor Assistant's employee file. The Clinical Director will ensure compliance with this requirement and the proper record keeping of compliance. The Project Director will review the Clinical Supervision Log monthly during a supervision session with the Clinical Director to ensure compliance. |
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
MLRC will ensure that clients are not discriminated against based upon their ethnicity. The Director of Quality & Development will update the Client Rights to include "Ethnicity" in the non-discrimination clause and copies will be given to, signed and returned by all current clients of MLRC. Any future clients of MLRC will receive the updated Client Rights, sign them and return them to be filed appropriately. The Director of Nursing will complete weekly audits of completed Client Rights forms to ensure compliance and the Director of Quality & Development will perform monthly spot check audits. The results from these audits will be documented and reported Quarterly during the facilities Committee of the Whole meeting. |