INITIAL COMMENTS
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This report is a result of a complaint investigation onsite and via email, conducted on January 7-8, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection conducted on January 7, 2025, the facility failed to provide a wall mirror in each bathroom.The first-floor bathroom in the Mansion was missing a wall mirror.
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Plan of Correction
On 1/8/2025 Mountain Laurel Recovery Center replaced the reference bathroom mirror. Mountain Laurel Recovery Center will conduct monthly rounds to ensure compliance, these rounds will be reviewed Quarterly in the Committee of the Whole Meeting. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted on January 7, 2025, the facility failed to store all food items off the floor.A package of water, bottles of flavored carbonated water, and cans of soda were observed being stored on the floor of the second-floor conference room.
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Plan of Correction
On 1/8/2025 Mountain Laurel Recovery Center removed all food items from the floor of the facility. Mountain Laurel Recovery Center will conduct monthly rounds to ensure compliance, these rounds will be reviewed Quarterly in the Committee of the Whole Meeting. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports and other administrative documentation, the facility failed to notify the Department of an unusual incident within the required three days.It was discovered that there was an incident in which the police were on premises. The facility did not submit a written unusual incident report to the Department within the regulatory three business days.
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Plan of Correction
The Director of Quality Improvement & Risk Management will complete an unusual incident report anytime there is Police Presence at Mountain Laurel Recovery Center as well as any other required state reportable incidents within the 3 business days following an unusual incident. All staff will be trained to report any unusual incidents to the Administrator. |
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 include the type and frequency of treatment and rehabilitation services on treatment plans in three of six records reviewed.Client # 1 was admitted on October 9, 2024, and discharged on October 21, 2024. The treatment plan dated 10/10/24 did not indicate the frequency of treatment and rehabilitation services.Client # 3 was admitted on October 21, 2024, and discharged on November 20, 2024. The treatment plans dated 10/22/24 and 11/7/24 did not indicate the type and frequency of treatment and rehabilitation services.Client # 4 was admitted on October 26, 2024, and discharged on November 25, 2024. The treatment plans dated 10/30/24 and 11/22/24 did not indicate the type and frequency of treatment and rehabilitation services.
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Plan of Correction
The clinical department will be retrained on regulation 709.52(a)(2) pertaining to a treatment plan including the type and frequency of rehabilitation services. This training will occur on 1/20/2025. This will be audited weekly by the Director of Clinical Services and the Quality Review Coordinator, or designee(s), with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. Findings will be reported to the Committee of the Whole Quarterly. |
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 an aftercare plan, in one of six records reviewed. Client # 5 was admitted on November 12, 2024, and discharged on December 10, 2024. The aftercare plan stated the client will be attending outpatient treatment; however, the date, time, name, and contact information of the provider for the outpatient treatment was missing.
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Plan of Correction
The clinical department will be retrained on regulation 709.63(a)(6) pertaining to an aftercare plan being completed fully and appropriately. This training will occur on 1/22/2025. This will be audited weekly by the Director of Clinical Services and the Quality Review Coordinator, or designee(s), with a target goal of 100% compliance. This audit will occur until 6 continuous months of 100% compliance has been achieved. Findings will be reported to the Committee of the Whole Quarterly. |