INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 21, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, God's Mountain Recovery Center, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following were deficiencies were identified during this investigation therefore a plan of corrections will be required.
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy of counseling sessions.
During a physical plant inspection that was conducted on February 21, 2020, it was observed that a camera was mounted on the ceiling in the group counseling area on the lower level. The video image from this camera was viewable on the video monitor, located in the downstairs utility room.
This information was shared with the facility staff in order to address the condition.
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Plan of Correction
The camera that was mounted on the ceiling in the group counseling was removed by maintenance with admissions director on 2/21/20. A staff meeting was conducted by Project Manager regarding privacy and confidentiality standards. It was discussed in this meeting that no clinical services may be provided in rooms that have cameras. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
During a physical plant inspection that was conducted on February 21, 2020, it was observed that the facility failed to prohibit heaters that are not permanently mounted or installed.
There were portable heaters in the group counseling room and in the facility dining room
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Portable heaters were removed from the group counseling room and facility dining room by admissions director. Staff meeting was conducted byProject Manager to ensure that staff is aware that portable heaters are prohibited in counseling center. |