INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 2, 2022 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:
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. The front group room windows and doors failed to have window coverings which allows for counseling sessions to be seen from the outside.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Immediately following this inspection, Compliance Manager informed Clinical staff of the changes regarding the front group room and rationale for the appropriate window coverings/treatments to be installed by maintenance staff and to remain in place for all future group therapy sessions to ensure privacy regulations are maintained. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill log for the months of January 2022 through September 2022, the facility failed to maintain a written fire drill record including documentation of exit routes used and whether the fire alarm or smoke detector was operative for all fire drills completed.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Immediately following this inspection, the fire drill record was updated to include the exit routes used and whether the fire alarm/smoke detectors were operative. This was implemented by the Compliance Manager and this updated documentation will continue for each monthly fire drill going forward. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility fire drill log for the months of January 2022 through September 2022, the facility failed to maintain a written documentation that the fire alarm or smoke detector was set off during each fire drill for all fire drills completed during January 2022 through September 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following this inspection, the fire drill record was updated to include that the fire alarms/smoke detectors were activated during each fire drill. This was implemented by the Compliance Manager and this updated documentation will continue for each monthly fire drill going forward. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on a review of seven partial hospitalization client records, the facility failed to document and compete and follow up information in one of three applicable client records.
Client #7 was admitted on June 14, 2022 and was discharged on September 16, 2022. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director implemented follow-up procedures to be completed by Intake/Client Care Coordinators with specific timeframe. Clinical Director reviewed procedure with the appropriate staff. Documentation will be submitted under the Discharge Tab in EMR. |
709.28 (c)(1) 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 shall be in writing and shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on one of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom the disclosure is being made.
Client # 11 was admitted on July 11, 2022 and was discharged on October 25, 2022. An informed and voluntary consent from the client for the disclosure of information dated July 11, 2022 for the purpose of an legal information did not provide the name of the person, agency or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed the release and discussed with the appropriate staff to ensure that all client information for release forms is accurate and necessary prior to completion. This procedure to complete these forms will continue for all admitted clients in the EMR system. |
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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the clients for the disclosure of information which is to include the purpose of the disclosure for all fourteen client records reviewed for the releases intended for a medical center, pharmacy and local hospital.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director contacted our Sunwave Health EMR provider and worked with them to include a purpose of disclosure section for all mentioned releases. Compliance Manager, Courtney Haley will audit releases to ensure these forms are being completed appropriately. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent which is to include documentation that the client was offered a copy of the release in all fourteen client records review for the releases intended for a medical center, pharmacy and local hospital.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director contacted our Sunwave Health EMR provider and worked with them to include check boxes that indicate an acceptance or refusal of a copy of the release of information on all above mentioned releases. Compliance Manager, Courtney Haley will audit each release form to ensure these are completed accurately. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of seven outpatient client records, the facility failed to document and compete and follow up information in two of three applicable client record.
Client #10 was admitted on June 20, 2022 and was discharged on August 24, 2022. There was no documentation of follow up information being completed in the client record.
Client #13 was admitted on February 10, 2022 and was discharged on May 10, 2022. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director implemented follow-up procedures to be completed by Intake/Client Care Coordinators with specific timeframe. Clinical Director reviewed procedure with the appropriate staff. Documentation will be submitted under the Discharge Tab in EMR. |