INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2025, 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 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a counselor on October 16, 2023 and was due to have the communicable disease trainings no later than October 16, 2024. There was no documentation in the personnel file of the completion of the TB/STD training 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
Employee #5 completed the required TB/STD training on 3/28/2025. The Director of Operations held an in-service on 4/15/2025 to discuss mandatory trainings and the importance of timeliness. The Director of Operations will audit training dates regularly. |
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, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the large group counseling room and dining room also used as a group room.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/17/2025 EMEC filed an exception for Counseling seen, not heard with DDAP. EMEC is asking for the exception to allow cameras in a recreational and communal area and be turned off during clinical group sessions. If the exception is not granted, the facility will transition groups to another room or office. |
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 client records, the facility failed to follow their policy to contact a client's emergency contact within twelve hours of leaving against medical advice in one out of two applicable records reviewed.
Client #6 was admitted to residential rehabilitation level of care on November 20, 2024 and discharged against facility advice on November 25, 2024. There is no documentation that the emergency contact was contacted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On April 15, 2025, the Clinical Director conducted an in-service with the clinical staff regarding the policy of a 12-hour contact for all patients discharged Against Medical Advice and for Administrative Discharges. The Clinical Director will also perform weekly audits of all clinical charts. |
709.28 (c) 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.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #4 was admitted on July 5, 2024 and discharged on September 26, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director held an in-service for all clinical staff on 4/15/2025 to discuss confidentiality and the requirement for all Release of Information to be signed upon intake. Weekly audits of clinical charts will be conducted by the Clinical Director. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection on April 9, 2025, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was nasal spray and poison ivy spray stored with the oral medication in the medication cart.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/15/2025 the nursing office stores topical medications in a separate area. On 4/15/2025 the Nursing department added a separation of medications to the monthly medication checklist to ensure all topical and ingestible medications are stored separately. All medication storage areas in the nursing department are audited monthly. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of facility records, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
An ambulance was at the facility on September 8, 2024. Upon review of unusual incidents submitted to the Department, it was found that this incident had not been reported at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Director of Operations will be solely responsible for reporting all unusual incidents for EMEC. The Clinical Director and Director of Operations will follow up on all unusual incidents within 24 hours and report within 3 business days or less to the Department. The unusual incident on September 8, 2024 will be reported immediately. |