INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 10-12, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of facility clean, safe, sanitary and in good repair at all times for the well-being of residents, employees and visitors.
It was observed, by DDAP staff, that the mechanism to close the main entrance door of the detox dorms, was broken and hanging from the top of the door in a manner that could cause injury.
Additionally, it was observed by DDAP staff, that on the second floor of the mansion, near the clinician offices, the bathroom had peeling and flaking paint.
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Plan of Correction
The facility immediately remediated the identified physical plant hazards. The broken door closure mechanism was replaced to ensure both safety and security. Additionally, the second-floor bathroom was repainted to eliminate peeling/flaking paint and maintain a sanitary environment. To sustain compliance, the Director of Environment of Care (EOC) has incorporated a weekly physical plant walkthrough into the preventative maintenance schedule to identify and address such issues proactively. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection and a review of the facility ' s food temperature logs, the facility failed to keep hot food at or above 140 F.
A review of the facility ' s food temperature logs indicated the following temperature non-compliances:
1/4/26, sausage casserole, 137.3 out of oven, at steam table 127.3 ham casserole at steam table 136.2 (breakfast)
1/5/26, pancakes 136.1 out of oven; omelets 99.7 out of oven; omelets 106 steam table (breakfast)
1/6/26, sweet potatoes at steam table, 139.4
1/7/26, tots 115.8 out of oven; omelets 133.3 out of oven; tots 109.4 steam table. (breakfast)
1/8/26, bacon, steam table 118.9 1/20/26, waffles 104.3 Out of oven; Waffles 98.5 steam table (breakfast.)
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Plan of Correction
Mountain Laurel Recovery Center has implemented standardized food service protocols to ensure all hot foods are held at or above 140°F. On 02/19/26, the Business Office Manager (ServSafe Certified) conducted comprehensive retraining for all dietary and relevant staff on temperature monitoring and documentation. Food temperatures will be logged at every meal, any noncompliance will be reported to Dietary Manager at the time of occurrence. To ensure sustained compliance, the Quality Review Coordinator will perform weekly audits of temperature logs, with findings reported to the Committee of the Whole monthly for oversight. |
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, the facility failed to not permit in the facility heaters that are not permanently mounted or installed.
DDAP staff observed a portable space heater in the detox medication room.
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Plan of Correction
In accordance with 28 Pa. Code § 705.8(2), all non-permanently mounted heating devices were immediately removed from the facility. Staff were formally re-educated on the strict prohibition of portable space heaters. The Director of EOC has added a specific "portable heater verification" to the monthly environmental safety rounds to ensure continued adherence to fire safety and licensure regulations. |
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 the Dietary Services policy and the Controlled Substance and Medication Destruction/Disposal policy, along with a review of facility incidents and staff/client interviews, the facility failed to adhere to written procedures for the management of treatment/rehabilitation services for clients.
The facility ' s " Dietary Services (PS-028) " policy notes: " Staff will take every precaution to ensure that the chance of contamination of food that may cause a client an adverse reaction is taken. This can be, but is not limited to preparing this meal separately, using new and clean utensils and tools to prepare the meal, etc. "
On October 3, 2025, the facility reported to DDAP an incident in which a female client, who was severely allergic to shellfish, reported oral swelling and tingling. The facility ' s internal investigation noted that shellfish were prepared for dining on the day of the incident. Additionally, it was noted in the investigation that cross contamination could have occurred.
Additionally, the facility ' s " Controlled Substance and Medication Destruction/Disposal (MM-009 " policy notes: " Unused medications are removed from medication stores by an authorized staff member at the time the medication is discontinued and then located in the designated area for destruction if not immediately destroyed. Controlled substances shall be destroyed immediately after they are removed if destruction shall occur onsite. "
The facility reported that this is not the current practice of the facility, but rather, clients must sign off on a document allowing for the destruction of unused medications. If the client does not sign off on this documentation medications are returned to them at the time of discharge.
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Plan of Correction
Mountain Laurel Recovery Center will retrain all dietary staff on safe food preparation protocols, specifically to include cross contamination safeguards during food preparation and serving by March 27th, 2026. Additionally as of 10/07/2025, the facility no longer serves shellfish.
Additionally, MLRC has revised the "Controlled Substance and Medication Destruction/Disposal (MM-009)" policy to align with facility practices. All nursing and authorized staff will be retrained on the revised MM-009 policy by March 27th, 2026. Ongoing compliance will be monitored by the Quality Review Coordinator through monthly audits of medication logs, with results reported to the Committee of the Whole.
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709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
Based on a review of facility job descriptions and personnel records, the facility failed to ensure accurate written job descriptions for project positions.
The facility ' s job description for the position of " Cook-Recovery " noted that an applicant for this position must have the following " Licenses/Designations/Certifications: " " SERV Safe Certification or similar food safety certification, where required by the state, facility. "
The facility was unable to provide documentation of a SERV Safe Certification or similar food safety certification for a newly hired cook.
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Plan of Correction
The facility has updated its hiring practices to ensure that all "Cook-Recovery" candidates possess, or obtain prior to employment, valid ServSafe or equivalent certifications before being assigned to any food preparation, cooking, or serving responsibilities.
The HR Manager will conduct a 100% audit of current dietary personnel files to ensure all required professional designations are present and unexpired.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to indicate the frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in one of six records reviewed.
Client # 4 was admitted on November 17, 2025, and discharged on December 6, 2025. The treatment plan dated 11/20/25 did not contain a frequency of group services.
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Plan of Correction
Clinical staff will undergo targeted retraining regarding documentation standards, by March 27th 2026, specifically the requirement to clearly define the type and frequency of services within the Individual Treatment Plan. The Director of Clinical Services (DCS) will conduct an audit of 10 Master Treatment Plans weekly until compliance is above 90 percent for two months. Monthly audits will then take place to ensure ongoing compliance. Audit data will then be reviewed in the Committee of the Whole to identify any further need for systemic adjustment. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two of six records reviewed.
Client # 2 was admitted on December 6, 2025, and discharged on January 24, 2026. The individual treatment and rehabilitation plan dated 12/29/25, indicated weekly individual sessions. There was no individual session documented for the week of 12/29/25.
Client # 5 was admitted on October 29, 2025, and discharged on November 26, 2025. The individual treatment and rehabilitation plan dated 11/1/25, indicated weekly individual sessions. There was no individual session documented for the week of 11/9/25.
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Plan of Correction
To ensure counseling services align with the Master Treatment Plan, the clinical team will receive training on matching service delivery to planned interventions by March 27th, 2026. The Director of Clinical Services (DCS) will conduct an audit of 10 charts weekly to ensure counseling services are provided according to the individual treatment plan until compliance is above 90 percent for two months. Monthly audits will then take place to ensure ongoing compliance. Audit data will then be reviewed in the Committee of the Whole monthly to identify any further need for systemic adjustment. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to provide a complete client record which shall include medication records.
Client # 3 was admitted on September 23, 2025, and discharged October 23, 2025. The medication administration record indicated the client received a doctor's order for a medication on 10/3/25; however, this medication was not listed on the discharge medication list as being given to the client at the time of discharge.
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Plan of Correction
Effective January 2026, the facility implemented a revised discharge protocol requiring nursing staff to complete a dedicated medication reconciliation section for every discharge summary. The RN Nurse Manager will conduct weekly retrospective audits of 100% of discharges to ensure the presence of complete medication records for two months. After two months of 100% compliance monthly audits will then take place to ensure ongoing compliance. Audit results will be reported monthly in the Committee of the Whole to ensure 100% sustained adherence. |