INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14-15, 2026, 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 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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705.4 (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 on May 14, 2026, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room. There was one camera in the small group room and three cameras in the large group room. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will have the security system temporarily turn the cameras off for the 2 identified group rooms/multi-purpose rooms until a decision is made with the exception that was filed for this citation. The facility CEO will file an exception by July 1, 2026 for this citation as the groups that are held in these rooms can only be seen, not heard, as our surveillance system does not have any audio. Additionally, these rooms are also multi-purpose rooms and are not exclusive to groups for the patients. These rooms are used during non-group times, for relaxation, art, journaling, reading, listening to music, etc., where patients are not directly with a staff member at all times and are in the room in a co-ed manner. The video surveillance supports the facility with safety measures for the patients when they are in the room during their free time. All patients sign a consent upon admission acknowledging that they are under video surveillance at all times except for in their bedrooms and restrooms. Additionally, with the volume of patients in this facility, the facility does not have any other rooms on the property that can be utilized exclusively for group therapy.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative documents, the facility failed to make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The 2025 annual report will be developed by the CEO and made public via the facility website by July 15, 2026.
The facility CEO will ensure development and website submission/posting of an annual report is completed for each calendar year by January 31st of the following year. The facility will have the report posted publicly on the facility's website upon completion. The facility CEO will continue to develop annual plans each calendar year thereafter and publicly post them on the facility's website. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in two of two applicable records reviewed.Client #5 was admitted to the detox program on December 22, 2025, and was involuntarily discharged on December 25, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.Client #12 was admitted to the residential program on February 2, 2026, and was involuntarily discharged on February 17, 2026. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility CEO corrected this prior to the annual site survey on May 14, 2026. The facility CEO implemented an "Intent to Discharge " Form in March 2026, when it was learned that the facility was not compliant with DDAP regulation regarding this. All patients who are or may be involuntarily discharged from the program are provided with an "Intent to Discharge" form. It is reviewed with each patient in person. The patient is asked to sign and date the form, along with a staff member. The patient is provided a copy of the form. |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information at seven days, six months and twelve months, per facility policy, in two out of two applicable discharged record reviewed. Client #4 was admitted on December 4, 2025, and was discharged on December 9, 2025. There was no documentation that a follow-up contact was made. Client #5 was admitted on December 22, 2025, and was discharged on December 25, 2025. There was no documentation that a follow-up contact was made. This is a repeat citation from the April 23 & 24, 2024, and April 16, 2025, licensing inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility CEO recognized in April 2026, that AMA and AD discharges were not being followed up on once discharged. The facility implemented a policy May 1, 2026, whereby all AMA and AD discharges are contacted within 24 business hours by the Utilization Review Specialist, or designee in their absence. If the Utilization review Specialist is unable to reach the discharged patient the first time, they will reach out again the next business day in an attempt to make contact. All successful completion discharges are followed up by our admissions team members who track our alumni patients at the following increments: seven days, six months and twelve months minimum. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing follow ups were submitted and approved by the Department for the April 23 & 24, 2024, and April 16, 2025, annual licensing inspections. Completing and documenting follow ups was again found to be a deficiency in the May 14-15, 2026, licensing process.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has implemented a Quality Improvement and Risk Committee within the Leadership Team to address Compliance, ensuring ensure the facility is following DDAP regulations and all Plan of Corrections submitted by this facility. Audits will be completed at least quarterly by a leadership member to ensure the facility is compliant with its current Plan of Corrections in all areas. |