INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Endless Mountains Extended Care, 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical site inspection on April 8, 2021, the facility failed to maintain furnishings in a state of good repair.
There was a chair in the kitchen/lounge area that had rips and had been taped back together.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On April 8, 2021 the property manager disposed of the chair so that the facility furnishings would entirely maintained in accordance with 705.3. |
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 site inspection on April 8, 2021, the facility failed to provide either individual paper towels or a mechanical dryer in all bathrooms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 8, 2021 in accordance with 705.6 the property manager provided all facility bathrooms with individual paper towels.
On April 8, 2021, the property manager added a section to mark off bathroom paper towels (as a task to be completed and checked off once complete) on the client technician shift report/room check. This report is completed daily by a specifically assigned Client Technician. These reports are checked each day by the property manager. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical site inspection on April 8, 2021, the facility failed to ventilate toilet and washrooms by exhaust fan or window.
The bathrooms located in bedrooms #3, #12 and #13 had no windows nor operable exhaust fans.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 705.6, on April 9, 2021, the property manager installed and/or repaired the exhaust fans located in the bathroom of bedroom # 3, 12, and 13 in order to provide proper ventilation.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on seven out of seven client records reviewed on April 8, 2021, the project failed to include documentation of the clients being notified that the project may not discriminate in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director contacted the EMR system provider to request a change to the verbiage within the "Client Rights" document in accordance with 709.30. On May 7, 2021, the document was changed to reflect the requirements.
All clients who began treatment at EMEC on or after May 7th, have signed the revised copy.
By Monday, June 7th the new Civil Rights will be signed by all current clients who started treatment before May 7th. |