INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and compliant investigation conducted on September 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Summit BHC Westfield, LLC d/b/a 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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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
Based on a physical site inspection that took place on September 21, 2021, the facility failed to keep the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The dining room had many chairs that were not in good repair and had tears in the seats. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will replace the chairs that are used in the dining room for persons served, with new chairs ordered and arrival expected by 11/15/2021. During weekly Leadership facility rounds, members of the MLRC Leadership Team will take note of any item that is observed to be in disrepair and complete a workorder for Facilities Manager to review items and determine if items are repairable or in need of replacement. The Maintenance supervisor will review with the CEO options for replacement and complete a purchase order. Facility Leadership members (CEO, CD, DON, CS, DQI/RM, FM and HR/BOM) will review the process for workorder completion as well as ensure any broken or potentially hazardous items are immediately removed. The Facility Manager will document in the monthly Environment of Care audits any items repaired or replaced as well as all workorders for the month which will be reviewed during quarterly COW meetings. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical site inspection that took place on September 21, 2021, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The facility video camera system is located in a recreation room which was used for counseling sessions. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At MLRC a few rooms double as group rooms and recreation, dining, activity and/or meditation rooms with the room observed on camera being one that doubles as a recreation room. Since this room has been used as both a group and recreation room, it was felt observing clients during recreation times in this room it would support the facility in ensuring patient safety. However, even though the camera may be shut down during group times so as to not record or even be used to remotely view the room, in order to abide by regulation 705.4 and ensure that the privacy of those we serve is protected MLRC will first shut down the functional use of the camera by 11/5/2021. Then by 11/19/2021 the camera will be fully removed, the time difference between functional use and removal is due to the fact that the full removal will require new ceiling tile, sheetrock, spackling and finally painting. The Director of Quality and Risk Management will supervise the shutting down of the camera's functional use as well as in ensuring the camera's full removal occurs, which will be documented in the EOC monthly reporting and reviewed during the Quarterly COW mtg. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical site inspection that took place on September 21, 2021, the facility failed to provide individual paper towels or a mechanical dryer in each bathroom. Bathrooms in rooms #103, #106 and #111 did not have paper towels or a mechanical dryer. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will stock all bathrooms of persons served with paper towels as needed. Once a week and during regular room cleaning MLRC Housekeeping staff will check each room to ensure that there are paper towels available in the bathroom and if a room doesn't have paper towels MLRC Housekeeping will place paper towels in that room's bathroom. MLRC Housekeeping will also provide paper towels for residents when requested as needed. MLRC leadership will develop a weekly check list for each room, that Housekeeping or Facility Manager completes weekly. The Facility Manager will monitor compliance during walk throughs and weekly check list sheet reviews documenting compliance or issues in the monthly Environment of Care report which will be reviewed during quarterly COW meetings. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical site inspection that took place on September 21, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.Sinks in bathrooms #106 and #205 had cracks in them with sharp edges.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC has replaced the sink in rooms 106. Room 205 would have been replaced, although the sink was broken upon delivery and is in the process of being returned with an expected replacement in the room by 11/15/2021(no sharp edges exist after sanding and caulking). MLRC leadership will develop a weekly check list for each room, that Housekeeping completes and turns into the Facilities Manager weekly. MLRC Housekeeping staff will check each room at least once a week to ensure that the room is in good standing. In the event that an item or facility of the room is in need of repair or replacement, MLRC Housekeeping staff will place a workorder with the Maintenance Supervisor. The Maintenance Supervisor will review the work order and determine if the item can be repaired or needs to be replaced. If the item is repairable the Facility Manager will repair it, removing it until this is done or if it needs replaced Facility Manager will remove it and complete a purchase request for a replacement. The Facilities Manager will document all incidents related to items in disrepair as well as if it was repaired or replaced in the monthly Environment of Care report which will be reviewed during the quarterly COW meetings. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records on September 21, 2021, the facility failed to document type and frequency of treatment and rehabilitation services in seven out of seven applicable records reviewed.Client #8 was admitted on July 13, 2021 and was still active at the time of the inspection. The comprehensive treatment plans dated July 28, 2021 and August 8, 2021 did not have type and frequency of treatment and rehabilitation services documented. Client #9 was admitted on August 9, 2021 and was still active at the time of the inspection. The comprehensive treatment plans dated August 12, 2021 and August 30, 2021 did not have type and frequency of treatment and rehabilitation services documented. Client #10 was admitted on August 20, 2021 and was still active at the time of the inspection. The comprehensive treatment plans dated August 20, 2021, August 24, 2021, August 31, 2021 and September 15, 2021 did not have type and frequency of treatment and rehabilitation services documented. Client #11 was admitted on August 23, 2021 and was still active at the time of the inspection. The comprehensive treatment plans dated August 26, 2021 and September 10, 2021 did not have type and frequency of treatment and rehabilitation services documented. Client #12 was admitted on March 4, 2021 and was discharged on April 16, 2021. The comprehensive treatment plans dated March 4, 2021, March 8, 2021, March 18, 2021 and April 1, 2021 did not have type and frequency of treatment and rehabilitation services documented. Client #13 was admitted on July 5, 2021 and was discharged on July 31, 2021. The comprehensive treatment plans dated July 11, 2021 and July 27, 2021 did not have type and frequency of treatment and rehabilitation services documented. Client #14 was admitted on December 17, 2020 and was discharged on January 17, 2021. The comprehensive treatment plans dated December 29, 2020, January 9, 2021 and January 16, 2021 did not have type and frequency of treatment and rehabilitation services documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will ensure that treatment type and frequency is documented in the individual treatment plan of all residents. MLRC will ensure it is included within the individual treatment plan in the interventions section- intervention 1 will be method(s), intervention 2 will be frequency and intervention 3 will be type(s). MLRC Quality Improvement Staff will audit all documentation no less than once monthly to ensure that all treatment plans have a "Type" and "Frequency" associated with the treatment service provided in the individual's Electronic Medical Record. MLRC Quality Improvement staff will document compliance within the Quality and Compliance portion of monthly reporting. MLRC will review the Quality and Compliance report during the quarterly COW. |