INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3, 2022 through October 5, 2022 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, it was determined that one employee hired as the Project and Facility Director did not meet the qualification requirements for the position.Employee #1 was hired as a counselor on May 2, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee did not have a qualifying degree.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CEO of Mountain Laurel Recovery Center will be filing for an exception based off of his years of experience in a drug and alcohol setting and human services as well as supervision of others. If the following is not approved a replacement that meets criteria will be appointed by Summit BHC. Working with Summit BHC human resources and MLRC human resources the criteria for the positions of Project Director and Facility Director will be included as part of consideration for appointment of the position. Summit BHC SUD Group-Division President will monitor and ensure, along with MLRC Director of Quality Improvement & Risk Management, any candidates meet qualifications before hire. |
704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.Employee #3 was promoted to the position of clinical supervisor on January 30, 2022 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor's degree, but only one and a half years of clinical experience, not the required minimum of three years.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on their credentials and experience MLRC Employee #3 will have their job title and description amended to not include any supervisory duties of clinicians.
Working together the HR director and the Clinical director will ensure all clinical staff meet qualifications and are able to complete the job accordingly. After selection and hire the Clinical director will monitor new staff to ensure they continue to meet criteria for their position. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of eight personnel records, it was determined that four employees hired as counselors did not meet the qualification requirements for the position, which include one year of clinical experience with a qualifying bachelor ' s degree.Employee #4 was hired as a counselor assistant on May 19, 2021 and was promoted to the position of counselor on January 2, 2022. At the time of promotion, the employee had a qualifying bachelor's degree, but only seven months of clinical experience.Employee #5 was hired as a counselor on June 13, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree, and no clinical experience.Employee #6 was hired as a counselor on April 4, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree, and no clinical experience.Employee #8 was hired as a counselor on August 22, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree, and no clinical experience.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per regulation MLRC CEO, HR director, and Clinical Director will realign staff in accordance with qualifications and regulations. Working together the HR director and the Clinical director will ensure all clinical staff meet qualifications and are able to complete the job accordingly. After selection and hire the Clinical director will monitor new staff to ensure they continue to meet criteria for their position. The CEO will train and ensure both Clinical Director and Human Resource Director understand the qualifications for clinical positions prior to hiring and maintaining staff compliance. As a check and balance our Director of Quality Improvement & Risk Management will audit for compliance in relation qualification regulations. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection on October 5, 2022, the facility failed to ensure that the kitchen contained an ABC rated fire extinguisher. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will place and maintain a portable fire extinguisher, with a minimum of ABC rating, in the kitchen area. MLRC safety officer will examine and verify fire extinguisher every month, logged on the safety inspection tag on the fire extinguisher. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of eight personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.Employee #1 was hired as the Project and Facility Director on May 2, 2022 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until June 2022.Employee #8 was hired as a counselor on August 22, 2022 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until September 12, 2022.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will provide fire safety training to all staff within their first week of hire conducted by the Safety Officer. MLRC HR Manager will audit files for this document during the first week of hire to ensure the process is completed in a timely manner. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documents and discussion with the facility director, the facility failed to document that the annual report for 2021 was completed and made available to the public.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Mountain Laurel Recovery Center will file for an exemption based on not being publicly funded. If the exception is not granted, Mountain Laurel Recovery Center will issue an annual report yearly to the public. Mountain Laurel Recovery Center CEO will implement this process and ensure it's completion. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The facility failed to follow their policy related to Against Medical Advice discharges of calling the Emergency Contact within twelve hours in two of two applicable records reviewed. Client #3 was admitted to the Rehab level of care on March 14, 2022 and discharged Against Medical Advice (AMA) on March 22, 2022. There was no documentation in the client record that the emergency contact was called. Client #10 was admitted to the Detox level of care on December 7, 2021 and discharged Against Medical Advice (AMA) on December 13, 2022. There was no documentation in the client record that the emergency contact was called. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
MLRC will provide training on their written procedures to ensure staff understand and follow the process, conducted by the Clinical Supervisor. MLRC Clinical Leadership will work with departments to maintain the process and ensure it's proper documentation by auditing files checking to ensure Emergency Contact within 12 hours was made. |
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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information to their individual funder in nineteen of nineteen applicable records reviewed. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Improvement & Risk Management will review and make any necessary adjustments to the voluntary consent allowing contact to their individual funder, insurance, or managed care organization(MCO). Clinical Director and clinical staff will be responsible for auditing releases of information to ensure they are filled out correctly before any information in disclosed. Director of Quality Improvement & Risk Management will monitor this process to ensure it does not occur again. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of twenty client records, the facility failed ensure that verbal orders were authenticated in writing by a physician or other medical professional within the regulatory timeframe in eight records reviewed. Client # 1 was admitted to the Rehab activity on September 27, 2021 and discharged on November 8, 2021. A verbal order was given on September 28, 2021 but was not authenticated in writing by a physician until October 7, 2021.Client # 4 was admitted to the Rehab activity from the Detox activity on June 15, 2022 and discharged on July 1, 2022. A verbal order was given on June 9, 2022 but was not authenticated in writing by a physician until June 17, 2022.Client # 6 was admitted to the Rehab activity from the Detox activity on September 24, 2022 and was active at the time of the inspection. Two verbal orders were given on September 13, 2022 but were not authenticated in writing by a physician.Client # 9 was admitted to the Detox activity on December 1, 2021 and discharged on December 6, 2021. A verbal order was given on December 1, 2021 but was not authenticated in writing by a physician until December 3, 2021.Client # 10 was admitted to the Detox activity on December 7, 2021 and discharged on December 13, 2021. A verbal order was given on December 7, 2021 but was not authenticated in writing by a physician until December 9, 2021.Client # 11 was admitted to the Detox activity on March 7, 2022 and discharged on March 14, 2022. A verbal order was given on March 7, 2022 but was not authenticated in writing by a physician until March 17, 2022.Client # 14 was admitted to the Detox activity on June 3, 2022 and discharged on June 8, 2022. A verbal order was given on June 4, 2022 but was not authenticated in writing by a physician until June 17, 2022.Client # 18 was admitted to the Partial activity from the Rehab activity on March 26, 2022 and discharged on May 4, 2022. A verbal order was given on February 24, 2022 but was not authenticated in writing by a physician until April 8, 2022.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will ensure that when a verbal order for medication was provided authentication shall occur within the 24 hour time period, or when appropriate based on level on care within 3 business days. The Director of Nursing will review charts to ensure orders have been provided within the appropriate timeframes. Director of Nursing will Coordinate with medical director when needed to ensure written orders have been provided meeting timeframes. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of twenty client records, the facility failed to document that the client was notified in writing of a decision to involuntarily terminate the client ' s treatment at the project in one of two applicable records reviewed.Client #4 was admitted to the Rehab activity on June 15, 2022 and was administratively discharged on July 1, 2022. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC has made a letter that specifically dictates the decision to administratively discharge the individual from treatment, as well as reason and rationale for this decision being made. This letter will be given to the individual at the time of discharge so that they have been made aware of the decision and why. A copy of the letter given to the client will be uploaded to their chart in the EMR in order to maintain record of this. The Clinical Supervisor will ensure that all members of the Clinical Team and Leadership Team have a copy of this letter and detailed instruction on how to complete and deliver it to the client being administratively discharged. The Clinical Supervisor will audit files of administratively discharged clients checking for the letter. The Director of Quality Improvement will spot check files for the letter. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of six records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in four of five applicable records reviewed.Client #16 was admitted to the Partial activity on October 29, 2021 and was discharged on November 10, 2021. The record contained documentation of only one individual counseling session per week offered the week of November 1, 2021.Client #18 was admitted to the Partial activity on March 26, 2022 and was discharged on May 4, 2022. The record contained documentation of only one individual counseling session per week offered the week of April 4, 2022.Client #19 was admitted to the Partial activity on October 26, 2021 and was discharged on November 22, 2021. The record contained documentation of only one individual counseling session per week offered the weeks of November 1, 2021, November 8, 2021, and November 15, 2021.Client #20 was admitted to the Partial activity on December 6, 2021 and was discharged on December 15, 2021. The record contained documentation of only one individual counseling session per week offered the week of December 6, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will retrain clinical staff on documentation standards for partial activity clients. Counselors will provide two weekly individual sessions to clients at partial activity. Clinical Supervisor will review with clinical staff weekly if any clients are at partial activity. Clinical Supervisor will audit files weekly to ensure partial activity clients receive two weekly individual sessions. |
709.83(a)(4) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Case consultation notes.
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Observations
Based on a review of six client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include documentation that the clients received case consultations in four of six applicable records reviewed. Client # 15 was admitted on March 25, 2022 and discharged on April 1, 2022. Client # 16 was admitted on October 29, 2021 and was discharged on November 10, 2021. Client # 19 was admitted on October 26, 2021 and was discharged on November 22, 2021. Client # 20 was admitted on December 6, 2021 and was discharged on December 15, 2021. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
MLRC will retrain clinical staff on documentation standards for case consultation notes. Clinical Supervisor will audit files weekly to ensure discharging have a case consultation note in their record. |
709.84(e) LICENSURE Project management services
709.84. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of six client records, the facility failed to follow their written client follow-up policy, to include attempted contact within one week of discharge, in two of six applicable records reviewed. Client # 15 was admitted on March 25, 2022 and discharged on April 1, 2022.Client # 18 was admitted on March 26, 2022 and was discharged on May 4, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will examine their policies and make adjustments, edits, or amend them as necessary to meet the cited regulation. MLRC will train staff on any policy adjustments ensuring that they follow the standard of the cited regulation. Alumni Coordinator will monitor the process to ensure that proper documentation is occurring. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days in two of three applicable records reviewed.Client # 1 was admitted on September 27, 2021 and discharged on November 8, 2021. A treatment plan update was completed on October 18, 2021 and another treatment plan update was due to be completed by November 2, 2021; however, the next treatment plan update was not completed until November 7, 2021.Client # 5 was admitted on June 8, 2022 and discharged on July 15, 2022. A treatment plan update was completed on June 23, 2022 and a treatment plan update was due to be completed by July 8, 2022; however, the next treatment plan update was not completed until July 14, 2022.These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will review the timeframes by which treatment plans will be reviewed and updated with clinical staff. Clinical staff will follow MLRC written procedures ensuring that treatment plans reviewed and updated at least every 14 days. Clinical Director will audit case files of their staff to ensure all appropriate timeframes are being followed. Director of Quality Improvement & Risk Management will monitor the audits to ensure compliance is followed. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of seven client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include documentation that the clients received case consultations in four of five applicable records reviewed. Client # 1 was admitted on September 27, 2021 and discharged on November 8, 2021. Client # 2 was admitted on November 15, 2021 and discharged on November 27, 2021. Client # 3 was admitted on March 14, 2022 and discharged on March 22, 2022.Client # 4 was admitted on June 15, 2022 and discharged on July 1, 2022.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
MLRC will examine their policies and make adjustments, edits, or amend them as necessary to meet the cited regulation. MLRC will train staff on any policy adjustments ensuring that they follow the standard of the cited regulation. Alumni Coordinator will monitor the process to ensure that proper documentation is occurring. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of seven client records, the facility failed to follow their written client follow-up policy, to include attempted contact within one week of discharge, in two of five applicable records reviewed. Client # 2 was admitted on November 15, 2021 and discharged on November 27, 2021. Client # 4 was admitted on June 15, 2022 and discharged on July 1, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will examine their policies and make adjustments, edits, or amend them as necessary to meet the cited regulation. MLRC will train staff on any policy adjustments ensuring that they follow the standard of the cited regulation. Alumni Coordinator will monitor the process to ensure that proper documentation is occurring. |