INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on May 10, 2023 between 10:00 AM and 10:30 AM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The bathroom in client room #1 had cracked tiles, rust on the hand bar and what appeared to be mold. The bathroom in client room #11 had rust on the hand bar and what appeared to be mold.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The conditions of the bathroom will be addressed by 6/1/2023. Maintenance staff along with Technician staff were inserviced in regard to weekly facility rounds by Operations Manager on 5/11/2023. |
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 and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The policy and procedure manual stated that the patient's counselor will immediately, no later than 12 hours of a patient leaving treatment, notify the patient's listed emergency contact, providing the patient has not revoked consent to notify said emergency contact.
Client #6 was admitted on July 13, 2022 and was discharged on September 27, 2022. Documentation of the notifying the emergency contact was due no later than September 28, 2023; however, there was no documentation that notification to the emergency contact was completed at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On May 19th, 2023 the clinical supervisor hosted a staff meeting/training post-inspection to discuss documentation of notifying emergency contacts no later than 12 hours.
A weekly audit will be conducted by the Client Care Coordinator and or Clinical Supervisor. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on consent to release information forms in seven of seven client records reviewed.
Each client record reviewed included a release of information to the funding source; however, on each form, in every record, the date, event, or condition upon which the consent to release information form would expire was not included.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On May 26th, 2023 the Clinical Supervisor will conduct an in-service/training on the proper completion of a consent form emphasizing the date, event, and condition in which the form would expire.
A weekly audit will be conducted by the Clinical Supervisor. A compliance report option has been added to our EMR as well. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client on consent to release information forms in seven of seven client records reviewed.
Each client record reviewed included a release of information to the funding source; however, on each form, in every record, there was no indication that a copy of the form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On May 26th, 2023 the Clinical Supervisor will participate in a Zoom meeting with the EMR representative. The purpose of which is to add a new consent of release for insurance providers. The 255 language was removed from the current release and new language including a check box for copy provided and one for denial of copy will be added. This will be implemented into our EMR system on 6/1/2023.
The Clinical Supervisor will conduct a weekly audit of all consents and a compliance report option has been added to our EMR. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(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 document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of seven records reviewed.
Client #1 was admitted February 13, 2023 and was active at the time of inspection. The individual treatment plan was completed on February 14, 2023; however, the plan did not include the type and frequency of rehabilitation services provided to the client.
Client # 3 was admitted February 21, 2023 and was active at the time of inspection. The individual treatment plan was completed on February 23, 2023; however, the plan did not include the type and frequency of rehabilitation services provided to the client.
Client # 5 was admitted November 1, 2022 and was discharged January 6, 2023. The individual treatment plan was completed on November 4, 2022; however, the plan did not include the type and frequency of rehabilitation services provided to the client.
Client # 6 was admitted July 13, 2022 and was discharged September 27, 2023. The individual treatment plan was completed on July 17, 2022; however, the plan did not include the type and frequency of rehabilitation services provided to the client.
Client # 7 was admitted August 11, 2022 and was discharged October 7, 2023. The individual treatment plan was completed on August 14, 2022; however, the plan did not include the type and frequency of rehabilitation services provided to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On May 19th, 2023, Clinical Supervisor conducted an in-service/training for all clinical staff for purposes of the treatment plan specifically type and frequency. The Clinical Supervisor explained that all goals must be specific, measurable, attainable, relevant, and time-bound. All Clinical staff demonstrated an understanding of the adjustments needed moving forward.
The Clinical Supervisor will conduct a file audit weekly to ensure that this policy is being followed as well as daily clinical meetings. |