INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23-24, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Endless Mountain Behavioral Health Center 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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705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide toilet paper at each toilet at all times. It was observed by DDAP staff, that both toilets in the Rec Room did not have any toilet paper. These findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
EMBHC will ensure that toilet paper will be available at each toilet, at all times. The facility cleaning person will check the bathrooms for toilet paper during daily cleaning rounds, replenishing and stocking the bathrooms as needed. EMBHC BHT staff will monitor the status of facility bathrooms, including toilet paper, daily during environment of care rounds, replenishing and restocking the toilet paper as needed. The Facility Manager will monitor and review the daily environment of care rounds and complete monthly environment of care spot checks, incorporating this into their monthly reporting which will be reviewed by the Facility CEO. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed to perform assigned tasks during emergencies, within seven days of hire. Employee #5 was hired on March 25, 2024, as a Counselor Assistant. and was still in this position as of the date of the inspection. The emergency training was completed on April 15, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
EMBHC will ensure that all staff are trained on facility emergency procedures during their first 7 days of employment. The facility Office Manager will schedule the training as part of their initial orientation, monitor that it is completed within the first 7 days, and maintain a staff log reflecting new hire orientation training completion dates. The Office Manager will incorporate this into their monthly reporting, which will be reviewed by the Facility CEO. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in three of six applicable client records reviewed.The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.Client # 7 was admitted to the inpatient non-hospital detoxification activity on February 28, 2024, and was discharged against medical advice on March 4, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.Client # 14 was admitted to the inpatient non-hospital detoxification activity on February 20, 2024, and was discharged against medical advice on February 23, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.Client # 16 was admitted to the inpatient non-hospital detoxification activity on March 13, 2024, and was discharged against medical advice on March 29, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
EMBHC will ensure that an individual's emergency contact is notified within 12 hours of discharging from the facility against medical advice. The Nurse on Duty or designee will contact the emergency contact within 12 hours of an individual leaving treatment against medical advice and document this contact in the individuals' electronic medical records. The Director of Nursing will monitor compliance and incorporate this into the monthly reporting, which will be reviewed by the Facility CEO. |
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 must be in writing and 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 a review of detox and residential client records, the facility failed to obtain a completed informed and voluntary consent which included the name of the person, agency, or organization to whom disclosure is made in two out of fourteen applicable records reviewed. Client # 15 was admitted on March 5, 2024, and was discharged on April 15, 2024. A completed release of information dated March 5, 2024, did not specify a party to whom information would be released. Client # 16 was admitted on March 13, 2024, and was discharged on March 29, 2024. A completed release of information dated March 13, 2024, did not specify a party to whom information would be releasedThese findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
EMBHC will ensure that the name of the person, agency, or organization is complete when a voluntary release of information is completed. The Admissions Director will provide a training to intake, BHT, counseling, and nursing staff on how to properly complete a release of information and this training will be incorporated into the new hire orientation process. The Admissions Director will monitor compliance and incorporate this into the monthly reporting, which will be reviewed by the Facility CEO. |
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.
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Observations
Based on a review of detox and residential client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in two out of fourteen applicable records reviewed. Client # 15 was admitted on March 5, 2024, and was discharged on April 15, 2024. A completed release of information dated March 5, 2024, for an insurance provider, did not contain a purpose for the disclosure. Client # 16 was admitted on March 13, 2024, and was discharged on March 29, 2024. A completed release of information dated March 13, 2024, for an insurance provider, did not contain a purpose for the disclosure. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
EMBHC will ensure that the purpose of disclosure on the individual's release of information is complete when a voluntary release of information is completed. The Admissions Director will provide a training to intake, BHT, counseling, and nursing staff on how to properly complete a release of information and this training will be incorporated into the new hire orientation process. The Admissions Director will monitor compliance and incorporate this into the monthly reporting, which will be reviewed by the Facility CEO. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of detox and residential client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of client in one out of fourteen applicable records reviewed.Client # 1 was admitted on April 22, 2024, and was still active at that the time of the inspection. A completed release of information dated April 22, 2024, for an insurance provider, did not contain a client signature. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
EMBHC will ensure that an individual's release of information is signed by the person completing the release and the individual when a voluntary release of information is completed. The Admissions Director will provide a training to intake, BHT, counseling, and nursing staff on how to properly complete a release of information and this training will be incorporated into the new hire orientation process. The Admissions Director will monitor compliance and incorporate this into the monthly reporting, which will be reviewed by the Facility CEO. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of detox client records, the facility failed to provide a complete client record, which includes a discharge summary on the day of discharge as per the facility's policy, in five of five applicable client records. Client #5 was admitted on March 22, 2024, and was discharged on March 25, 2024. There was no documentation of a discharge summary in the client record. Client #6 was admitted on February 22, 2024, and was discharged on February 23, 2024. There was no documentation of a discharge summary in the client record. Client #7 was admitted on February 28, 2024, and was discharged on March 4, 2024. There was no documentation of a discharge summary in the client record. Client #8 was admitted on February 29, 2024, and was discharged on March 4, 2024. There was no documentation of a discharge summary in the client record. Client #9 was admitted on February 17, 2024, and was discharged on February 20, 2024. There was no documentation of a discharge summary in the client record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
EMBHC will ensure that a discharge summary is completed on the day of discharge. The counselor or case manager will complete the discharge summary on the day the individual discharges from the facility. The Clinical Director will monitor compliance and incorporate this into the monthly reporting, which will be reviewed by the Facility CEO. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of detox client records, the facility failed to provide a complete client record, which includes follow-up information within seven days of discharge as per the facility's policy, in five of five applicable client records. Client #5 was admitted on March 22, 2024, and was discharged on March 25, 2024. There was no documentation of a follow-up contact in the client record. Client #6 was admitted on February 22, 2024, and was discharged on February 23, 2024. There was no documentation of a follow-up contact in the client record. Client #7 was admitted on February 28, 2024, and was discharged on March 4, 2024. There was no documentation of a follow-up contact in the client record. Client #8 was admitted on February 29, 2024, and was discharged on March 4, 2024. There was no documentation of a follow-up contact in the client record. Client #9 was admitted on February 17, 2024, and was discharged on February 20, 2024. There was no documentation of a follow-up contact in the client record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
EMBHC will ensure that within 7 days of discharge a follow-up will be attempted. The Admissions Director or designee will reach out to an individual for a follow-up and document the follow-up or attempted follow-up in the individual's electronic medical record. The Admissions Director will monitor for compliance and incorporate this into their monthly reporting, which will be reviewed by the Facility CEO. |
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
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Observations
Based on a review of residential client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven applicable records reviewed.Client #10 was admitted on March 22, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 1, 2024, did not document client support services. Client #11 was admitted on March 29, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 4, 2024, did not document client support services. Client #12 was admitted on March 28, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 1, 2024, did not document client support services. Client #13 was admitted on February 7, 2024, and was discharged on March 8, 2024. The comprehensive treatment plan, completed February 14, 2024, did not document client support services.Client #14 was admitted on February 20, 2024, and was discharged on February 23, 2024. The comprehensive treatment plan, completed February 23, 2024, did not document client support services.Client #15 was admitted on March 5, 2024, and was discharged on April 15, 2024. The comprehensive treatment plan, completed March 12, 2024, did not document client support services.Client #16 was admitted on March 13, 2024, and was discharged on March 29, 2024. The comprehensive treatment plan, completed March 25, 2024, did not document client support services.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
EMBHC will ensure that the proposed type of support service will be documented in the individual's master treatment plan. On 4/30/24 a section to include the proposed type of support services was added to the master treatment plan. The counselor will complete this section with the individual when the master treatment plan is completed. The Clinical Director will monitor for compliance and incorporate this into their monthly reporting, which will be reviewed by the Facility CEO. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which includes a discharge summary on the day of discharge as per the facility ' s policy, in two of four applicable client records. Client #14 was admitted on February 20, 2024, and was discharged on February 23, 2024. There was no documentation of a discharge summary in the client record. Client #16 was admitted on March 13, 2024, and was discharged on March 29 2024. There was no documentation of a discharge summary in the client record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
EMBHC will ensure that a discharge summary is completed on the day of discharge. The counselor or case manager will complete the discharge summary on the day the individual discharges from the facility. The Clinical Director will monitor for compliance and incorporate this into their monthly reporting, which will be reviewed by the Facility CEO. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 residential client records, the facility failed to provide a complete client record, which includes follow-up information within seven days of discharge as per the facility's policy, in four of four applicable client records. Client #13 was admitted on February 7, 2024, and was discharged on March 8, 2024. There was no documentation of a follow-up contact in the client record. Client #14 was admitted on February 20, 2024, and was discharged on February 24, 2024. There was no documentation of a follow-up contact in the client record. Client #15 was admitted on March 5, 2024, and was discharged on April 15, 2024. There was no documentation of a follow-up contact in the client record.Client #16 was admitted on March 13, 2024, and was discharged on March 29, 2024. There was no documentation of a follow-up contact in the client record.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
EMBHC will ensure that within 7 days of discharge a follow-up will be attempted. The Admissions Director or designee will reach out to an individual for a follow-up and document the follow-up or attempted follow-up in the individual's electronic medical record. The Admissions Director will monitor for compliance and incorporate this into their monthly reporting, which will be reviewed by the Facility CEO. |