INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 23-25, 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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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on client and staff interviews along with a review of Behavior Health Associate (BHA) hours worked and the client census on May 14-21, June 8,15, July 3, 9-12, 14-16, August 4, 12, 17, September 2, 12, 18, 2025, the facility failed to ensure sufficient support staff for the safe operation of the project.The Observation of Clients policy reports checks will be completed at 15, 20, 30 or 60-minute intervals. All checks must be verified visually. Sleeping patients must be observed for three rise and falls of the chest.The facility's Behavior Health Associate (BHA) job description indicates that a BHA is to conduct safety checks, check clients for contraband and manage client valuables and belongings, facilitate educational and recreational groups, assist with unit cleaning, provide transportation, monitor facility equipment and supplies, and other duties as assigned.5/14/25 - Client census = 65 Residential and 5 Detoxification. 0 BHA ' s working between the hours of 12 am - 4 am. 1 BHA working between the hours of 4:30 am - 6:30 am, 2 BHA ' s working between 6:30 am - 7: 00 am.5/16/25 - Client census = 55 Residential and 6 Detoxification. 2 BHA ' s working between the hours of 2:30-3:30 am. 1 BHA working between 11 pm - 12 am.5/17/25 - Client census = 54 Residential and 7 Detoxification. 1 BHA working between the hours of 12 am - 2am. 0 BHA ' s working between 2 am - 2:30 am. 1 BHA working between the hours of 2:30 am - 6 am. 2 BHA ' s working between 7 am- 7:30 am, 6 pm - 6:30 pm, 7:30 pm-8pm. 2 BHA, and 11 pm-12 am.5/18/25 - Client census = 54 Residential and 7 Detoxification. 2 BHA's working between the hours of 12 am - 6 am, 10 am - 11 am, and 7 pm - 8 pm.5/19/25 - Client census = 57 Residential and 7 Detoxification. 2 BHA ' s working between 1 am - 1:30 am. 1 BHA working between2 am - 2:30 am.5/20/25- Client census = 56 Residential and 7 Detoxification. 2 BHA ' s working between 1 am - 2 am. One BHA working between 2 am - 2:30 am. 2 BHA ' s working between the hours of 2:30 am - 5:30 am.6/8/25 - Client census = 55 Residential and 7 Detoxification. 1 BHA working between the hours of 12 am - 2 am. 0 BHA ' s working between 2 am - 2:30 am. 1 BHA working between the hours of 2:30 am - 6 am. 2 BHA ' s working between11 am - 11:30 am. 6/15/25 - Client census = 58 Residential and 5 Detoxification. 2 BHA ' s working between the hours of 12 am - 2 am. 1 BHA working between 2 am - 2:30 am. 2 BHA ' s working between 2:30 am - 3 am. 1 BHA working between 3 am - 3:30 am. 2 BHA ' s working between the hours of 3:30 am - 6 am, and 10:30 am -11:30 am.7/3/25 - Client census = 74 Residential and 5 Detoxification. 0 BHA ' s working between the hours of 12 am - 6 am. 2 BHA ' s working between the hours of 6 am - 7:30 am. 7/9/25 - Client census = 65 Residential and 7 Detoxification. 1 BHA working between the hours of 12 am - 6am. 2 BHA ' s working between 10 am-11am.7/10/25 - Client census = 64 Residential and 7 Detoxification.2 BHA ' s working between 4 am - 4:30 am, 7 pm- 7:30 pm, 10 pm - 10:30 pm, and 11 pm - 12 am.7/11/25 - Client census = 64 Residential and 7 Detoxification. 2 BHA ' s working between the hours of 12 am - 6 am, 7 am - 8 am, 10 am - 10:30 am, and 11 pm-12 am.7/12/25 - Client census = 59 Residential and 7 Detoxification. 2 BHA ' s working between the hours of 12 am - 6 am, 10 am - 11 am, and 6:30 pm - 8:30 pm.7/14/25 - Client census = 61 Residential and 5 Detoxification. 0 BHA ' s working between the hours of 12 am - 6 am.7/15/25 - Client census = 61 Residential and 6 Detoxification. 2 BHA ' s working between the hours of 12 am - 3 am, 1 BHA working 3 am - 3:30 am, 2 BHA ' s working between the hours of 3:30 am - 5 am, 1 BHA working between 5 am - 5:30 am, 2 BHA ' s working between 5:30 am - 6 am, and 11 pm - 12 am. 7/16/25 - Client census = 65 Residential and 6 Detoxification. 2 BHA ' s working between the hours of 12 am - 3 am, 1 BHA working 3 am - 3:30 am, 2 BHA ' s working between the hours of 3:30 am - 6 am, and 10:30 am - 11 am.8/4/25 - Client census = 55 Residential and 7 Detoxification. 0 BHA ' s working between the hours of 12 am - 6 am. 2 BHA ' s working between 6 am - 7 am, 10 am - 11 am, and 4:30 pm - 6 pm.8/12/25 - Client census = 57 Residential and 4 Detoxification. 0 BHA ' s working between the hours of 12 am - 6 am. 1 BHA working between 6 am - 6:30 am, 2 BHA ' s working between 6:30 am - 7:30 am.8/17/25 - Client census = 58 Residential and 7 Detoxification. 1 BHA working between the hours of 12 am - 6 am. 2 BHA ' s working between 6 am - 6:30 am, 7 am - 10 am, and 1 pm - 2pm.9/2/25 - Client census = 65 Residential and 5 Detoxification. 1 BHA working between the hours of 12 am - 6 am.9/12/25 - Client census = 65 Residential and 6 Detoxification. 0 BHA ' s working between the hours of 12 am - 6 am. 2 BHA ' s working between 6 am - 6:30 am, 5 pm - 5:30 pm, 6 pm - 8 pm, 8:30 pm - 10 pm, and 11:30 pm - 12 am. 9/18/25 - Client census = 65 Residential and 6 Detoxification. 1 BHA working between the hours of 12 am - 6 am. 2 BHA ' s working between 7 am - 8 am.
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Plan of Correction
Mountain Laurel Recovery Center (MLRC) self-imposed a moratorium on admissions on 10/03/25, in order to hire and train additional support staff. Corporate Recruiting has been actively engaged throughout this process to assist with the recruitment of BHA staff. The admissions moratorium ended on 10/15/25. Further training for support staff, including nursing and the MLRC leadership team, is ongoing at this time, with an expected completion date of 10/31/25. This training includes cross-training on BHA-related responsibilities, for client observation and safety rounding. A return demonstration of competency will be required for all staff completing the training to verify both completion and understanding, with documentation filed in each employee's HR file.
As of 10/03/25, MLRC has implemented a staffing oversight process to ensure continuous compliance with 704.3(c) regarding sufficient clerical and support staff for safe and efficient operations.
- The facility Human Resource Director (HRD) completes daily audits of Behavioral Health Associate (BHA) staffing levels, both scheduled and actual, to confirm appropriate coverage on every shift. Results are reviewed and reported directly to the CEO and Milieu Coordinator to verify compliance with established minimum staffing ratios and client safety requirements.
- The facility Clinical Supervisor or clinical designee reports any acuity-related concerns during the daily FLASH meeting to ensure appropriate staffing adjustments are made in real time.
- Facility staffing grid for BHA staffing to be generated by CEO pending approval through Governing Board. To be completed by 10/20/25.
- Weekly analysis of staffing trend data will be completed by the DQI/RM, and monthly reporting of compliance outcomes during the Committee of the Whole (CoW) meeting. This will be monitored with a goal of 100% compliance for 90 consecutive days and quarterly to the Governing Board until compliance is sustained.
MLRC continues to utilize assistance from the company's Corporate Recruiting Department to assist in staff recruitment and hiring.
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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
The facility failed to follow written procedures for two policies.Based on a review of client records and the Code Green procedures, the facility failed to follow their written Code Green procedures. The Code Green - Physical Altercation Response Reference Guide indicates that nursing staff must complete an immediate evaluation after a physical altercation.Client # 1 was admitted on 5/7/25 and discharged on 5/20/25. The client record did not contain documentation of nursing staff completing an immediate evaluation of the injuries sustained from a physical altercation.Based on a review of the facility's Client Complaints and Grievances Policy and the Client Communication Forms from May through September 2025, the facility failed to follow its policy. The Client Complaints and Grievances Policy indicates that Mountain Laurel will review/respond to all client grievances, provide a written response to the client within seven days of receiving the grievance; and document all grievances including the final disposition. There was no resolution documented in 15 out of 33 grievances reviewed.
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Plan of Correction
As of 10/19/25, The Director of Nursing (DON) completed re-training of all direct care nursing staff on Procedure titled "The Code Green ? Physical Altercation Response Reference" to ensure that an evaluation is completed immediately after a physical altercation, to include the documentation of any injuries in the patient's medical record. Attestations completed and filed in each employee's HR file.
To monitor and ensure compliance, the DON or designee will audit 100% of all medical records involving patients who are involved in physical altercations to ensure that an evaluation is completed immediately after the incident, with a goal of 100% compliance for 90 consecutive days. Compliance will be reported monthly to the Committee of the Whole (CoW) and quarterly to the Governing Board until compliance is sustained.
If non-compliance is identified, a corrective action plan will be submitted to the Committee of the Whole and monitored until full compliance is restored.
On 10/17/25, the Client Advocate received re-training from the DQI/RM to ensure compliance with 709.24(a)(3) regarding licensure, treatment, and rehabilitation management and reinforce adherence to the facility's Policy # RI-002 "Client Complaints and Grievances," to provide clients with a written response within seven days of receiving a grievance and properly documenting the grievance, including the final disposition, on a newly initiated facility log. Attestation completed and filed in the employee HR file.
To monitor and ensure compliance, the Director of Quality or designee will audit the facility's monthly grievance log to ensure written responses are completed within seven days of receiving grievances and there is documentation of the final disposition of the grievance, with a goal of 100% compliance for 90 consecutive days. Compliance will be reported monthly to the Committee of the Whole (CoW) and quarterly to the Governing Board until compliance is sustained.
If non-compliance is identified, a corrective action plan will be submitted to the Committee of the Whole and monitored until full compliance is restored.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare plans, in three of eight records reviewed.Client # 4 was admitted on 6/15/25 and was discharged on 7/24/25. The client record did not contain documentation of an aftercare plan.Client # 5 was admitted on 7/6/25 and discharged on 8/6/25. The client record did not contain documentation of an aftercare plan.Client # 7 was admitted 5/27/25 and discharged on 7/1/25. The client record did not contain documentation of an aftercare plan.
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Plan of Correction
On10/16/25, the Clinical Supervisor trained Clinical Services staff on Policy #RS-009, titled "Discharge Summary" related to Aftercare Plans to ensure clients receive an aftercare plan when discharged routinely from the facility, including regulation 709.53(a)(9). Attestations completed and filed in each employee's HR file.
To monitor and sustain compliance, the Clinical Supervisor or designee will conduct monthly audits of ten discharged medical records to verify that an Aftercare Plan is completed prior to discharge, with a continued goal of 100% compliance. Audit outcomes are reported in daily Clinical Flash meetings, reviewed monthly at the Committee of the Whole (CoW), and quarterly to the Governing Board until compliance is sustained.
In addition to clinical auditing oversight, the Quality Review Coordinator audits all discharging client charts weekly to ensure the presence of a completed Aftercare Plan. Findings are communicated directly to the Clinical Supervisor, CEO, and DQI/RM, and these audits are ongoing to ensure compliance with §709.53(a)(9). Once six consecutive months of 100% compliance have been achieved, the review process will transition to a monthly sampling of discharged client charts.
If non-compliance is identified, a corrective action plan will be submitted to the Committee of the Whole and monitored until full compliance is restored.
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709.17(a)(4) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
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Observations
Based on client and staff interviews, a review of incident reports, grievances, client records, facility policies, and other administrative documentation, it was found that gross incompetence, negligence or misconduct in the operation of the facility was present. From May through September 2025, there were 18 instances of physical altercations, sexual assaults and/or harassment, and other acts of aggression.There were 10 incidents involving physical assault, 2 incidents involving other acts of aggression, 4 incidents of sexual assault, and 2 incidents of sexual harassment.
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Plan of Correction
The leadership and staff of Mountain Laurel are fully committed to achieving and maintaining full compliance with all applicable state regulations governing our operations. We recognize the importance of adhering to these standards to ensure the safety, quality of care, and well-being of the patients we serve.
Please note that the leadership team has undertaken a comprehensive review of our policies, procedures, and practices, and is actively implementing corrective actions to address any identified gaps. This includes:
- New leadership and strengthened accountability structures
- Enhanced corporate leadership involvement and advisement
- Updating and reinforcing staff training programs
- Enhancing documentation and auditing processes
- Implementing systems to ensure timely reporting and follow-up
- Monitoring and evaluating compliance through regular internal audits and oversight
- Strengthened Governing Board oversight
- Utilizing gap analyses and performance improvement projects to identify trends and reduce adverse events
Our facility remains committed to transparency, accountability, and continuous improvement. We will continue to work diligently to ensure that all regulatory requirements are consistently met and sustained.
In response to the following violation of 709.17(a)(4), the facility has enacted the following actions:
DQI/RM has developed a Performance Improvement plan focused on the prevention, reporting, and management of client aggression, sexual assaults, and harassment. This includes:
- Weekly analysis of staffing trend data audits (to be reported up to CoW)
- Enhanced admissions screening to identify clients with a history of aggression or sexually acting-out behaviors
- Activation of an Incident Action Committee (IAC) following any Level 3 or 4 incident to review events and implement immediate corrective actions
- Staff education on incident reporting requirements and trauma-informed de-escalation practices;
- Data trend analysis of all occurrences involving aggression, sexual assault, or harassment to identify patterns and guide preventive strategies
- Ongoing DQI/RM oversight, with trends and progress reported monthly at the Committee of the Whole (CoW) to track outcomes and evaluate the effectiveness of the PI plan.
As a result of the developed PI plan, upon the occurrence of any Level 3 or 4 incident involving any type of alleged or actual aggression and/or any type of alleged or actual client boundary violations, A special Incident Action Committee (IAC) will now be convened by no later than the next business day to review the actual incidents and implement actions to mitigate their occurrence on an immediate and continuous bases.
The clinical team has reviewed and updated the admissions screening tool to emphasize identification of individuals with a history of aggression or sexually acting-out behaviors. These risk factors are integrated into the pre-admission process to ensure appropriate clinical determination for admission to MLRC. Admissions staff were re-trained on 10/08/25 regarding intake assessments specific to evaluating a history of violence or sexually acting-out behavior. Training attestations have been completed and filed in each employee's HR file.
Staff will complete mandatory retraining on de-escalation techniques, trauma-informed care, and incident reporting requirements. This training will be assigned in HealthStream and completed by all direct care staff by 10/24/25. Documentation of completion will be maintained by the Human Resource Director.
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