INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10-12, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-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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704.7(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 personnel records, the facility failed to ensure that each counselor met the qualifications of the position at the time of hire in one of seven applicable personnel records reviewed.
Employee #11 was hired as a counselor on April 4, 2022. The employee had a qualifying bachelor's degree; however, they did not have any documented clinical experience at the time of hire. The employee did not reach the required one year of clinical experience until April 4, 2023.
This is a repeat citation from the October 5, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 11 met qualifications as defined in regulation 704.7(b) on April 3, 2023. To prevent reoccurrences should the facility employ a counselor assistant the Director of Clinical Services will provide direct supervision to all counselor assistants as defined in regulation 704.9. The Director of Clinical Services will document all supervision provided to counselor assistants. The Human Resources Director will verify the supervision log, for 100% compliance, at least once monthly for all counselor assistants employed at the facility. |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure that each annual written individual training plan was based upon an employee's previous education, experience, current job functions, and performance in thirteen of thirteen personnel records reviewed.
In each personnel record reviewed, the individual training plan was identical and was not individualized based upon each the specific employee's previous education, experience, current job functions and job performance.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will ensure that each department director individualizes training plans with input from each staff member who works in their department. The Human Resources Director will verify through an audit of staff files that training plans have been appropriately made and documented at least once quarterly for all staff with the target goal of 100% compliance. The Human Resources Director will report their findings to the Committee of the Whole quarterly. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in three of five applicable personnel records reviewed.
Employee # 11 was hired as a counselor on April 4, 2022 and was due to have HIV/AIDS and TB/STD trainings no later than April 4, 2023. The HIV/AIDS training was not completed until April 25, 2023 and the TB/STD training was not completed until May 2, 2023.
Employee # 12 was hired as an admissions employee on August 2, 2021 and was due to have HIV/AIDS training and TB/STD training no later than August 2, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 14 was hired as an admissions counselor on August 9, 2021 and was due to have HIV/AIDS training and TB/STD training no later than August 9, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will ensure that all staff members receive the aforementioned training in accordance with regulation 704.11(c). The training hours will be logged by each department head for their staff. The Human Resources Director will verify through an audit of staff files, for 100% compliance, that training has occurred in accordance with regulation 704.11(c) bi-annually. The Human Resources Director will report their findings to the Committee of the Whole bi-annually. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2022, through December 31, 2022 training year in one of one applicable personnel record reviewed.
Employee # 10 was hired as a counselor on November 21, 2021. The personnel record documented 13 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services and the Clinical Supervisor will ensure that all clinical staff members receive the aforementioned training hours in accordance with regulation 704.11(f). The training hours will be logged on their training plans and submitted to HR. The Human Resources Director will verify through an audit of clinical staff files, for 100% compliance, that training has occurred in accordance with regulation 704.11(c) bi-annually. The Human Resources Director will report their findings to the Committee of the Whole bi-annually. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on October 10, 2023, between 10:30 AM and 12:00 PM, the facility failed to ventilate each toilet and washroom by an exhaust fan or a window.
The bathroom exhaust fans in rooms 105 and 206 were not operable and there were no operable windows in the bathrooms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Operations Director will check monthly that all exhaust fans in bathrooms are in working order, and document it through their monthly walkthrough. This walkthrough will be submitted for verification to the Director of Quality Improvement & Risk Management monthly. The Facility Operations Director will report their findings quarterly to the Committee of the Whole. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on October 10, 2023, between 10:30 AM and 12:00 PM, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in the massage therapy room.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Operations Director will ensure that any heaters not permanently mounted are not present in the facility and document it through their monthly walkthrough. This walkthrough will be submitted for verification to the Director of Quality Improvement & Risk Management monthly. The Facility Operations Director will report their findings quarterly to the Committee of the Whole. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on October 10, 2023, between 10:30 AM and 12:00 PM, the facility failed to limit smoking to designated smoking areas.
There were cigarette ashes found in rooms 107, 104, and 208.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will reeducate clients on approved smoking areas at the facility. This will also be addressed as part of a client's orientation to the facility. When completing observation rounds staff will check to ensure that clients are not smoking in non-designated smoking areas. Any client who is found smoking in a non-designated smoking area will be re-directed to the appropriate area and their primary counselor will address the behavioral issue further. |
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 and the policy and procedure manual, the facility failed to follow the project ' s written procedures for the management of treatment/rehabilitation services for clients in two of three applicable client records reviewed.
The policy and procedure manual stated that the patient ' s counselor will notify the patient ' s listed emergency contact, providing the patient has not revoked consent to notify said emergency contact upon client leaving against medical advice.
Client #6 was admitted on December 10, 2022 and was discharged on December 15, 2022. There was no documentation that contact was made with the emergency contact at the time of inspection.
Client #16 was admitted on April 27, 2023 and was discharged on May 6, 2023. There was no documentation that contact was made with the emergency contact at the time of inspection.
This finding was reviewed with 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 audit the files of clients that discharged AMA weekly and submit to the Director of Quality Improvement & Risk Management for review. This audit will continue to occur until a minimum of six continuous months of 95% compliance have occurred. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure was made in seventeen of seventeen client records reviewed.
An informed and voluntary consent in each client record for the funding source did not include the name of the person, agency or organization to whom the disclosure is to be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
MLRC will be adopting a new electronic medical record. The previous formatting of ROI's as referred to in this citation will not be present or accessible in the new electronic medical record. The updated ROI format will have all areas noted in this citation present. A representative sample size audit will occur quarterly to ensure adherence. This audit will continue to occur until a minimum of six continuous months of 100% compliance have occurred. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in seventeen of seventeen client records reviewed.
There was no documentation that a copy was offered for the informed and voluntary consent from the client for the disclosure of information contained in the client record to the funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new Electronic Medical Record will provide an updated ROI format where all ROI's include functionality to document whether a copy was offered to the client. An ROI will not be able to be completed in the new system without this section being completed appropriately. |
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 client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in three of three applicable client records reviewed.
Client # 5 was admitted on March 8, 2023 and was administratively discharged on March 11, 2023. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
Client # 9 was admitted on February 1, 2023 and was administratively discharged on February 3, 2023. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
Client #15 was admitted on August 1, 2023 and was administratively discharged on August 7, 2023. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services or the Clinical Supervisor will audit the charts of administratively discharged clients monthly. This audit will be submitted to the Director of Quality Improvement & Risk Management for review. The Director of Clinical Services or the Clinical Supervisor will present their findings quarterly to the Committee of the Whole. This audit will continue to occur until a minimum of six continuous months of 95% compliance have occurred. |
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 client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in two of four applicable client records reviewed.
Client # 12 was admitted to the inpatient non-hospital activity on August 15, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 22, 2023 and an update was due no later than September 22, 2023; however, the update was not completed until October 6, 2023.
Client # 13 was admitted to the inpatient non-hospital activity on August 28, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 8, 2023 and an update was due no later than October 8, 2023; however, the update was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services or the Clinical Supervisor will audit the charts of current clients monthly to ensure treatment plan updates are occurring as written in regulation 709.52(b). This audit will be submitted to the Director of Quality Improvement & Risk Management for review. The Director of Clinical Services or the Clinical Supervisor will present their findings quarterly to the Committee of the Whole. This audit will continue to occur until a minimum of six continuous months of 95% compliance have occurred. |