INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 16, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
During an onsite complaint investigation conducted on October 16, 2024, it was observed that the facility failed to not permit a heater that was not permanently mounted or installed.A portable heater that was not permanently mounted or installed was observed in the Facility Director's office.
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Plan of Correction
EMBHC will ensure that all heaters are permanently mounted or installed in the facility. The Facility Manager will complete weekly environment of care rounds, and document their findings on a weekly environment of care inspection form. In addition, all staff will utilize maintenance request forms as needed to immediately address this type of issue. The Facility Manager will incorporate the weekly environment of care inspections, maintenance requests, and completions 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 client records and the Treatment/Rehabilitation Management policy, the facility failed to follow its written procedures for the management of treatment/rehabilitation services for clients in five of five records reviewed.The Treatment/Rehabilitation Management policy indicates that at a minimum, monitoring of clients in the detoxification services, should be done every 4 hours for the first 72 hours, and as ordered by the medial director or designee thereafter. Monitoring includes changes in mental status, vital signs, response to detoxification medications, CIWA/COWS. Client # 1 was admitted on August 7, 2024, and discharged on August 11, 2024. Vital signs and CIWA/COWS were not documented every 4 hours for the first 72 hours of treatment. Vital signs were documented twice on 8/8/24 and twice on 8/9/24. No vital signs were documented on 8/10/24. A CIWA was documented once on 8/8/24, 8/9/24 and 8/10/24.Client # 2 was admitted on August 10, 2024, and discharged on August 17, 2024. Vital signs and CIWA/COWS were not documented every 4 hours for the first 72 hours of treatment. There was no documentation of vital signs for 8/11/24 or 8/12/24. A CIWA was documented once on 8/10/24, none on 8/11/24, and once on 8/12/24. Client # 3 was admitted on August 1, 2024, and discharged on August 3, 2024. Vital signs and CIWA/COWS were not documented every 4 hours. There was documentation of vital signs once on 8/1/24, once on 8/2/24 and none on 8/3/24. A CIWA was documented one time on 8/1/24 and one time on 8/2/24. Client # 4 was admitted on August 4, 2024, and discharged on August 5. 2024. Vital signs and CIWA/COWS were not documented every 4 hours. Vital signs, a CIWA and a COWS were each documented once on 8/4/24 and once on 8/5/24. Client # 5 was admitted on August 9, 2024, and discharged on August 15, 2024. Vital signs and CIWA/COWS were not documented every 4 hours for the first 72 hours of treatment. Vital signs and a CIWA were each documented once on 8/10/24 and once on 8/11/24.
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Plan of Correction
Following consultation with our Medical Director and a review of best practices, EMBHC is updating its policy and procedures for monitoring vital signs and withdrawal assessments (COWS/CIWA) within the 3.7WM level of care. This revision aims to optimize individualized care and ensure timely responses to client needs. The following will be reflected in our updated policy and procedures:
1. Revised Monitoring Protocols:
Vital signs, COWS, and/or CIWA assessments will occur three times daily during the initial stages of treatment. Once a client shows consistent stability, as indicated by their vital signs and withdrawal scores, this frequency will be adjusted to twice daily until discharge from the 3.7WM level of care.
2. Observation and On-Demand Assessments:
All individuals in the 3.7WM level of care are observed by staff every 30 minutes. If, during these observations, an individual is seen to be in distress or reports feeling physically unwell, an immediate set of vital signs will be taken, and COWS or CIWA assessments will be completed. This protocol ensures that any emergent health concerns are promptly identified and addressed.
3. Staff Training and Documentation Compliance:
To ensure consistent adherence to these protocols, staff members will undergo training on the updated monitoring and assessment standards. Emphasis has been placed on recognizing signs of distress, conducting on-demand assessments, and the critical importance of accurate, timely documentation.
The Facility CEO will ensure the policy and procedure is revised, reviewed the changes with the Director of Nursing, and the Director of Nursing will oversee the implementation within the Medical/Nursing Department. The Director of Nursing and/or a designee will monitor compliance, incorporating their findings into their 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 client records, the facility failed to provide a complete client record, which is to include a discharge summary, in two out of five records reviewed.Client # 1 was admitted on August 7, 2024, and discharged on August 11, 2024. The client record was missing documentation of a discharge summary.Client # 5 was admitted August 9, 2024, and discharged on August 15, 2024. The client record was missing documentation of a discharge summary.
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Plan of Correction
Based on an internal review, it appears that most of the discharge summaries that are missed are for individuals that leave treatment against medical/staff advice. EMBHC will ensure that a discharge summary is completed on the day of discharge for all treatment discharges by implementing the following standard operating procedure; that a counselor or case manager completes the discharge summary for AMA/ASA discharges from the 3.5 level of care and a nurse will complete the discharge summary for AMA/ASA discharges from the 3.7WM level of care. The Facility CEO will develop the standard operating procedure, review it with department supervisors, and department supervisors (Clinical Director and Director of Nursing) will implement the process within their departments. The Clinical Director and Director of Nursing will monitor for compliance and incorporate it into their monthly reporting which will be reviewed by the Facility CEO. Lastly, EMBHC will complete discharge summaries in the charts sited during this survey. |