INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 28, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pocono Mountain Recovery Center, LLC 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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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to include documentation of a preliminary treatment and rehabilitation plan in one of five records reviewed.
Client # 5 was admitted on March 15, 2025, and discharged on April 11, 2025. There was no documentation of a preliminary treatment and rehabilitation plan in the client record.
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Plan of Correction
Compliance will be regularly monitored via biweekly chart audits by the Medical Records Clerk. The audits' outcomes will be shared with the Director of Clinical Services and Manager of PHP Clinical Services. Clinical leadership will address any deficiencies immediately with the clinical staff with action plans implemented as necessary. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 written documentation of the type and frequency of treatment and rehabilitation services, in one of five client records reviewed.
Client # 2 was admitted on March 5, 2025, and discharged on March 14, 2025. The Master Treatment Plan dated March 9, 2025, did not include individual counseling sessions or the frequency of these sessions.
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Plan of Correction
Compliance will be regularly monitored via biweekly chart audits by the Medical Records Clerk. The audits' outcomes will be shared with the Director of Clinical Services and Manager of PHP Clinical Services. Clinical leadership will address any deficiencies immediately with the clinical staff with action plans implemented as necessary. |
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.
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Observations
Based on a review of client records, the facility failed to provide documentation of individual counseling at least twice weekly, in four of five records reviewed.
Client # 1 was admitted on February 3, 2025, and discharged on March 12, 2025. For the week of 2/23/25, one individual counseling session was documented, dated 3/1/25. For the week of 3/2/25, one individual counseling session was documented, dated 3/2/25.
Client # 3 was admitted on March 6, 2025, and discharged on March 22, 2025. For the week of 3/2/25, one individual counseling session was documented, dated 3/7/25. For the week of 3/9/25, one individual counseling session was documented, dated 3/14/25. There was no documentation for individual counseling sessions found in the client record for the week of 3/16/25.
Client # 4 was admitted on March 21, 2025, and discharged on May 5, 2025. For the week of 4/6/25, one individual counseling session was documented, dated 4/12/25. There was no documentation for individual counseling sessions found in the client record for the week of 4/20/25.
Client # 5 was admitted on March 15, 2025, and discharged on April 11, 2025. For the week of 3/23/25, one individual counseling session was documented, dated 3/26/25.
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Plan of Correction
Compliance will be regularly monitored via biweekly chart audits by the Medical Records Clerk. The audits' outcomes will be shared with the Director of Clinical Services and Manager of PHP Clinical Services. Clinical leadership will address any deficiencies immediately with the clinical staff with action plans implemented as necessary. |