INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28-31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
The facility failed to ensure all trash, garbage, and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week. During the physical plant inspection on October 29, 2019, licensing staff observed trash and debris scattered around the dumpster in addition to the trash receptacle overflowing with garbage. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Once this issues was identified, all trash was picked up and disposed of immediately. However, in the future MLRC will ensure that all facility grounds are clean and free of litter, trash and garbage by completing daily observational rounds of the facility property. Any garbage that is visible and not in the proper receptacle will be disposed of properly.
MLRC will ensure that facility garbage receptacles are not over flowing. Observation and confirmation of this will be conducted during daily facility observational rounds and documented on the daily Environment of Care sheet. Receptacles on facility property will be regularly emptied to ensure that garbage will not be overflowing from the receptacle. Daily observational rounds will be completed by the Facilities Manager and/or his designee and reported on in MLRC's monthly EOC report and/or immediately if facility EOC concerns arise. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records on October 28-31, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 2 and 3. Client #2 was admitted on July 1, 2019 and discharged on August 13, 2019. A consent to release information form, dated July 26, 2019, to a government agency, permitted release of alcohol/drug use history, diagnostic impressions, symptomology, biographic, family, psychological and social history, and discharge summary/aftercare recommendations. Client #3 was admitted on July 18, 2019 and discharged on August 30, 2019. An email dated August 20, 2019 between facility staff and a government employee, disclosed information outside the limits established by 4 Pa. code 255.5(b). These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the May 3, 2019 licensing inspection.
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Plan of Correction
MLRC will ensure compliance with PA Code 255.5, respecting and upholding the confidentiality of all clients. A new Release of Information has been created and only that information which is detailed in PA Code 255.5 will be released to government agencies, such as but not limited to: corrections, police, etc. These changes were reviewed informally with Admissions, Nursing Staff and Clinicians on 11/30/2019. A formal training will be conducted by 12/6/2019 with Clinicians, Admissions and Nursing Personnel on confidentiality, ROIs and the requirements of PA Code 255.5 by the Quality Improvement Coordinator. The Admissions Director will complete weekly audits of ROI's to ensure compliance and the Quality Improvement Coordinator will perform monthly spot check audits. The results from the ROI audits will be documented and reported on Quarterly during the facilities Committee of The Whole Meeting. |
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 client records on October 28-31, 2019, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of all of their rights in client record # ' s 1, 2, 3, 4, 5, 6, and 7. The written acknowledgement did not disclose to the clients that they may not be discriminated against based on their creed. 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 creed. The Quality Improvement Coordinator has updated the Client Rights to include "Creed" in the non-discrimination clause and copies will be given to, signed and returned by all current clients of MLRC by 12/6/2019. Any future clients of MLRC will receive the updated Client Rights, sign them and return them to be filed appropriately. The Admissions Director will complete weekly audits of completed Client Rights forms to ensure compliance and the Quality Improvement Coordinator will perform monthly spot check audits. The results from these audits will be documented and reported on Quarterly during the facilities Committee of the Whole meeting. |