INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted April 1-2, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Mountain Laurel Recovery Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on staff interviews and a review of administrative documentation during a complaint investigation conducted on April 1-2, 2025, the facility failed to have one FTE primary care staff person available for every seven clients in the detoxification unit. These designated staff may not have any duties other than in the detoxification unit.On 3/13/2025 there were 9 clients in the detoxification unit with one nurse dedicated to the unit and one nurse shared with the rehabilitation and treatment unit. On 3/14/2025 there were 12 clients in the detoxification unit with one nurse dedicated to the unit and one nurse shared with the rehabilitation and treatment unit.On 3/15/2025 there were 14 clients in detoxification unit with one nurse dedicated to the unit and one nurse shared with the rehabilitation and treatment unit.
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Plan of Correction
By 03/30/2025, Mount Laurel Recovery Center's (MLRC) Chief Executive Officer (CEO) and Quality/ Risk Director (QRD) attested to understanding of regulation 704.12(a)(1)(i) and the state mandated ratio for detox clients and nursing responsibilities. In addition,
MLRC nursing staff received re-education related to detox unit assignments and nursing responsibilities on 3/31/25. Education will be added to nurse specific job specific training that occurs during New Hire Orientation.
Sustainability:
The IDON, or designee, will review nursing assignment sheets daily to ensure that appropriate ratios and duty assignments are maintained at all times, with a goal of 100% compliance each shift Data will be aggregated and compliance reported monthly to the facility's Committee of the Whole and quarterly to the Governing Board who maintains ultimate oversight of the facility.
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709.62(a)(1) LICENSURE Admission Criteria
709.61. Exceptions to the general standards for free-standing treatment activities.
Due to the nature of this detoxification activity, projects of this kind need not comply with 709.24 (a) (2) and 709.24 (a) (3) (relating to treatment/rehabilitation management).
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(1) Criteria for admission.
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Observations
Based on a review of client records and facility policies during a complaint investigation conducted on April 1-2, 2025, the facility failed to follow its Belongings and Contraband Policy.The policy indicates that during the Assessment and Intake, all belongings are documented on the belongings checklist for the Person Served. After completed the Person Served will sign, along with staff who inventoried belongings, and nurse to sign as witness. Upon discharge, staff reviews belongings record with the Person Served, has them sign indicating that all valuables and belongings have been returned and staff signing as a witness, acknowledging this.Client #1 was admitted on January 3, 2025 and discharged on January 13, 2025. The Belongings Checklist documenting the client's belongings during admission and returned at discharge was not included in the client chart or elsewhere.
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Plan of Correction
By 04/07/2025, MLRC's Behavioral Health Associates (BHA) were retrained on Policy # _PS-004 titled "Contraband and Belongings" to ensure understanding that upon admission, all client's belongings are to be inventoried on a personal belongings form that shall be signed by the client, and reviewed with the client upon discharge. Education will be added to BHA job specific training that occurs during New Hire Orientation.
Sustainability:
The Milieu Coordinator, or designee, will audit 15 medical records each month to ensure that a Personal Belongings form was completed at admission, with a goal of 100% compliance for 60 consecutive days. Data will be aggregated and compliance reported monthly to the facility's Committee of the Whole and quarterly to the Governing Board who maintains ultimate oversight of the facility.
In the event non-compliance is identified, the employee will receive written re-education on the process.
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records during a complaint investigation conducted on April 1-2, 2025, the facility failed to ensure a complete client record to include a discharge summary.Client #1 was admitted on January 3, 2025 and discharged on January 13, 2025. The client chart did not contain a discharge summary at the time of the investigation.
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Plan of Correction
By 04/23/2025, all counselors were retrained on regulation 709.63(a)(7), as it relates to completion of a discharge summary for each client. Education will be added to counselor specific job specific training that occurs during New Hire Orientation.
Sustainability:
The Director of Clinical Services (DCS) or designee will review 15 discharged medical records each month to ensure clients have a completed discharge summary in the medical record, with a goal of 100% compliance for 60 consecutive days. Data will be aggregated and compliance reported monthly to the facility's Committee of the Whole and quarterly to the Governing Board who maintains ultimate oversight of the facility.
In the event non-compliance is identified, the employee will receive written re-education on the process.
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