D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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MOUNTAIN EDGE RECOVERY CENTER, LLC
310 SUGAR HILL ROAD
UNION DALE, PA 18470

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Survey conducted on 10/10/2024

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on October 9, 2024 through October 10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mountains Edge Recovery Center, LLC 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:	Plan of Correction
704.7(b) LICENSURE Counselor Qualifications 704.7. Qualifications for the position of counselor. (a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios). (b) Each counselor shall meet at least one of the following groups of qualifications: (1) Current licensure in this Commonwealth as a physician. (2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues. (3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues. (4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues. (5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues. (6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
Observations Based on a review of four personnel records, the facility failed to ensure that each counselor met the required experience in one of three applicable records reviewed. Employee #2 was hired as a counselor on July 31, 2023; however, this employee does not possess a qualifying degree from an accredited college, nor a full certification as an addiction counselor by a statewide certification body. These findings were reviewed with project staff during the licensing process.	Plan of Correction Employee #2 was reclassified as a Counselor Assistant effective 10/10/2024 and will remain as such until either completion of a Bachelor's or CAAC is obtained. The clinical Director met with Employee #2 and agreed to have either a Bachelor's or CAAC by June 2025. The clinical director will monitor progress toward obtaining CAAC. All future potential counselor candidates must have a bachelor's degree or a full certification in addiction counseling.
709.28 (c) 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.
Observations Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of nine client records reviewed. Client #8 was admitted on March 15, 2024, and was discharged on April 10, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred. These findings were reviewed with project staff during the licensing process.	Plan of Correction The Clinical Director and Director of Compliance reeducated intake staff on protocols regarding informed and voluntary consent for funding sources and updated the consent form for funding sources in our electronic medical record in June 2024. The compliance department will monitor the completion of these releases of information during their weekly chart audit.
709.28 (c) (3) 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: (3) Purpose of disclosure.
Observations Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the record that included documentation of the purpose of disclosure in five of nine records reviewed. Client #1 was admitted on July 11, 2024, and was active at the time of the inspection. Three release of information forms that were signed by the client on July 11, 2024, for an ex-employer, the funding source and a local hospital did not document the purpose of disclosure on the form. Client #2 was admitted on July 29, 2024, and was active at the time of the inspection. Three release of information forms that were signed by the client on July 31, 2024, for a legal representative, the funding source and a local hospital did not document the purpose of disclosure on the form. Client #3 was admitted on August 5, 2024, and was active at the time of the inspection. Two release of information forms that were signed by the client on August 5, 2024, for an emergency contact and funding source did not document the purpose of disclosure on the form. Client #8 was admitted on March 15, 2024, and was discharged on April 10, 2024. Two release of information forms that were signed by the client on March 15, 2024, for a local hospital and a family member did not document the purpose of disclosure on the form. Client #9 was admitted on April 16, 2024, and was discharged on April 29, 2024. Four release of information forms that were signed by the client on April 16, 2024, for a local hospital and three family members did not document the purpose of disclosure on the form. These findings were reviewed with project staff during the licensing process.	Plan of Correction The Clinical Director and Director of Compliance reeducated all staff on protocols regarding the purpose of disclosure on all releases of information. The compliance department will monitor all releases of information to ensure the purpose for release is completed during their weekly chart audit. The clinical director will spot check releases of information during monthly supervision audits. As of 10/23/2024, our electronic medical record system requires all fields on the release to be completed before the form is eligible for client or staff signatures. Client #1 & #2 discharged before the POC was implemented and Client #3 completed a new release of information with the purpose of disclosure completed.
709.82(d)(1) LICENSURE Treatment and rehabilitation services 709.82. Treatment and rehabilitation services. (d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented: (1) Individual counseling, at least twice weekly.
Observations Based on the review of client records, the project failed to document two weekly individual counseling sessions in seven of seven partial hospitalization clients reviewed. Client #1 was admitted on July 11, 2024, and was active at the time of the inspection. The project only documented one individual counseling session for the weeks of July 15, 2024 through July 19, 2024, July 22, 2024 through July 26, 2024, July 29, 2024 through August 2, 2024, August 5, 2024 through August 9, 2024, August 12, 2024 through August 16, 2024, August 19, 2024 through August 23, 2024, August 26, 2024 through August 30, 2024, September 2, 2024 through September 6, 2024, September 9, 2024 through September 13, 2024, September 16, 2024 through September 20, 2024, September 23, 2024 through September 27, 2024 and September 30, 2024 through October 4, 2024. Client #2 was admitted on July 29, 2024, and was active at the time of the inspection. The project only documented one individual counseling session for the weeks of August 5, 2024 through August 9, 2024, August 12, 2024 through August 16, 2024, August 19, 2024 through August 23, 2024, August 26, 2024 through August 30, 2024, September 2, 2024 through September 6, 2024, September 9, 2024 through September 13, 2024, September 16, 2024 through September 20, 2024, September 23, 2024 through September 27, 2024 and September 30, 2024 through October 4, 2024. Client #3 was admitted on August 5, 2024, and was active at the time of the inspection. The project only documented one individual counseling session for the weeks of August 12, 2024 through August 16, 2024, August 19, 2024 through August 23, 2024, August 26, 2024 through August 30, 2024, September 2, 2024 through September 6, 2024, September 9, 2024 through September 13, 2024, September 16, 2024 through September 20, 2024, September 23, 2024 through September 27, 2024 and September 30, 2024 through October 4, 2024. Client #4 was admitted on December 28, 2023, and was discharged on May 16, 2024. The project only documented one individual counseling session for the weeks of January 22, 2024 through January 26, 2024 and February 26 through March 1, 2024. Client #5 was admitted on January 11, 2024, and was discharged on May 16, 2024. The project only documented one individual counseling session for the weeks of January 22, 2024 through January 26, 2024, February 27, 2024 through March 3, 2024, April 3 2024 through April 7, 2024 and April 10, 2024 through April 14, 2024. Client #6 was admitted on January 18, 2024, and was discharged on April 11, 2024. The project only documented one individual counseling session for the weeks of January 22, 2024 through January 26, 2024, January 29, 2024 through February 2, 2024, February 5, 2024 through February 9, 2024, February 12, 2024 through February 16, 2024, February 19, 2024 through February 23, 2024 and February 26, 2024 through March 1, 2024. Client #7 was admitted on April 3, 2024, and was discharged on June 13, 2024. The project only documented one individual counseling session for the weeks of April 22, 2024 through April 12, 2024, April 15, 2024 through April 19, 2024, April 22, 2024 through April 26, 2024, April 29, 2024 through May 3, 2024, May 6, 2024 through May 10, 2024, May 13, 2024 through May 17, 2024, May 20, 2024 through May 24, 2024, May 27, 2024 through May 31, 2024 and June 3, 2024 through June 7, 2024. These findings were reviewed with project staff during the licensing process.	Plan of Correction After further examination of the client record, the clinical director coordinated with our electronic medical record vendor to add an additional section to the Multi-Day Clinical Progress Note to allow the documentation of two individual sessions to be reflected in the multi-day note. All clinical staff have been educated on this amendment to the multi-day note. The clinical director will monitor the compliance of this documentation adjustment.
709.92(a)(2) LICENSURE Treatment and rehabilitation services 709.92. 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.
Observations Based on a review of outpatient client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of the two applicable client records reviewed. Client #8 was admitted on March 15, 2024, and was discharged on April 10, 2024. The individual treatment and rehabilitation plan was completed on March 20, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. Client #9 was admitted on April 16, 2024, and discharged on April 29, 2024. The individual treatment and rehabilitation plan was completed on April 23, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. These findings were reviewed with project staff during the licensing process.	Plan of Correction The clinical director reeducated clinical staff on the requirement to complete every section of the treatment plan in its entirety, including the type, frequency, and rehabilitation services for each individual treatment plan. The compliance department will monitor the full completion of each treatment plan during their weekly chart audit, and the clinical director will spot-check treatment plans during our monthly supervision audit.