INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 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 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of nine personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #8 was hired on October 1, 2024 as a counselor assistant and is still in that position. Employee #8 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #8 did not receive direct observation from October 1, 2024 to January 1, 2025. There was no documentation that direct observation occurred with each client that the counselor assistant was assigned to provide therapeutic counseling services. Employee #8 did not receive close supervision from January 1, 2025 through March 14, 2025. During close supervision on January 24, 31, February 7, 21, 28, and March 7, 2025 there was no documentation of direct observation.
Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " .
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. "
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
To correct the immediate deficiency identified in the supervision of Employee #8, a remedial direct observation plan has been implemented. This plan addresses the missed direct observation period from October 1, 2024, through January 1, 2025. Beginning May 1, 2025, and continuing through July 8, 2025, Employee #8 will complete a 12-week remedial direct observation program. During this period, 100% of all client sessions will be observed in real time by either a trained counselor or a clinical supervisor. Each observation will be documented on a DDAP-compliant direct observation form, signed by both the observer and Employee #8, and stored in her personnel file. In addition to this remedial action, the facility has restructured the supervised period timeline. Because the original three-month observation requirement was not met, the supervision timeline has been reset to begin May 1, 2025. Employee #8 is now scheduled to complete three months of remedial direct observation (May 1, 2025 ? July 23, 2025), followed by nine months of close supervision (July 24, 2025 ? April 22, 2026). To prevent recurrence, the facility implemented policy and SOP changes effective April 25, 2025. All newly hired counselor assistants with only a high school diploma will now have a supervision plan preloaded into the EMR task system upon onboarding. Supervisors are required to complete a Direct Observation Verification Form for each client session during the first three months of employment. Additionally, the clinical supervisor must review and co-sign the weekly log of observations. To ensure continued compliance, the Director of Quality will conduct random audits of 50% of counselor assistant files on a quarterly basis, with findings reported monthly to the CEO. Furthermore, all clinical staff received targeted training on DDAP 704.9 supervision requirements on April 20, 2025. The completion dates for the corrective phases are as follows: the remedial direct observation period is set from May 1, 2025 to July 23, 2025, and the close supervision period extends from July 24, 2025, to April 22, 2026. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water at or below 120 degrees. The men ' s bathroom in the dining hall and the female ' s bathroom in the recreation hall ' s hot water was recorded at 140 degrees.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of April 15, 2025, the facility will ensure that daily water temperature checks are documented on the environmental checklist by the Facility Manager. If any readings exceed 120°F, the issue will be addressed within 24 hours and rechecked. This process will begin on April 16, 2025. The metric for compliance is that daily checks must be documented and reported in the quarterly leadership meeting. The responsible party is the Facility Manager, with oversight by the CEO. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs from June 2024 through February 2025, the facility failed to maintain a written fire drill record that included whether the fire alarm or smoke detector was operative.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By April 15, 2025, fire drill logs were updated to include verification of alarm and smoke detector functionality. Starting April 16, 2025, drill logs must reflect this change, with 100% of them including such verification. The Safety Officer is responsible for this correction, with monthly report submissions to the CEO and quarterly reviews in leadership meetings. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from June 2024 through February 2025, the facility failed to conduct a fire drill during sleeping hours at least every six months. According to the fire drill log there was an overnight fire drill that occurred on July 24, 2024; however, there was no documentation of another overnight drill occurring six months later.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective April 16, 2025, and no later than July 31, 2025, fire drills will be conducted during the overnight hours of 12:00 AM to 6:00 AM every six months. The requirement is to have two overnight drills documented annually. The Facility Manager and Director of Nursing are responsible, with quarterly compliance monitoring. |
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 two out of three applicable records reviewed.
Client #13 was admitted to the inpatient nonhospital residential level of care on February 24, 2025 and discharged against facility advice on February 26, 2025. There was no documentation that the facility contacted the emergency contact.
Client #15 was admitted to the inpatient nonhospital residential level of care on October 10, 2024 and discharged against facility advice on October 11, 2024. There was no documentation that the facility contacted the emergency contact.
This is a repeat citation from the April 23 & 24, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 1, 2025, the Charge Nurse will confirm that emergency contact notifications are completed within 12 hours following an Against Medical Advice (AMA) discharge. This initiative will begin on the same date. The metric is reviewed monthly. Oversight will be provided by the Lead Nurse and Director of Nursing, with monthly reviews by the Director of Quality and Compliance. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of thirteen records reviewed.
Client #9 was admitted to the inpatient nonhospital residential level of care on March 13, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a family member signed by the client on April 9, 2025, that did not identify the purpose for disclosure.
This is a repeat citation from the April 23 & 24, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 1, 2025, the staff completing the intake will ensure that the "purpose of disclosure" is completed on every Release of Information (ROI) form. This correction was made on April 20, 2025. The Director of Quality and Compliance is responsible for conducting monthly audits, with monthly reporting to the CEO. |
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 16, 2025, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was anti itch cream along with medicated pads stored with the oral medication in the medication cart located in the detoxication unit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of April 18, 2025, and starting April 22, 2025, medication cart inspections must verify that external-use medications are stored separately. Compliance will be measured for four consecutive weeks, after which inspections will shift to a monthly schedule. The Charge Nurse is responsible, submitting reports to the Director of Nursing, who in turn presents the data in quarterly leadership meetings. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in two out of thirteen client records.
Client # 2 was admitted to the inpatient nonhospital detoxication level of care on April 12, 2025 and was still active at the time of the inspection. The client was prescribed two medications, and the prescriptions stated that one tablet was to be taken at 2PM. The medication administration records showed that the one medication was not given at 2PM on April 13, 2024 and one medication was not given at 2PM on April 14, 2025. There was no additional documentation indicating a reason why the medications were not given as prescribed.
Client # 8 was admitted to the inpatient nonhospital residential level of care on April 2, 2025 and was still active at the time of the inspection. The client was prescribed a medication, and the prescription stated that one tablet was to be taken at 8PM. The medication administration records showed that the medication was not given on April 12 or 15, 2025 at 8PM. There was no additional documentation indicating a reason why the medications were not given as prescribed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective May 1, 2025, and starting May 1, 2025, a cross-check will be conducted five times a week between medication administration records and client charts to verify proper administration or refusal documentation. The 2nd Shift Lead Nurse is responsible, with weekly reviews conducted alongside the Director of Nursing and monthly reporting to the 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 client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of one applicable discharged record reviewed. The facility ' s policy and procedures manual states that follow up contacts occur at 7 days, six and twelve months.
Client #5 was admitted on September 15, 2024 and was discharged on September 22, 2024. There was no documentation that a seven day or six month follow up contact was made.
This is a repeat citation from the April 23 & 24, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning May 1, 2025, the facility will document follow-up contacts within 7 days, 6 months, and 12 months for all discharges. The correction was implemented on May 1, 2025. This is the responsibility of the Lead Behavioral Health Technician and the Admissions team, with audits conducted monthly by the Director of Quality and Compliance and submitted to the CEO. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the facility policy and procedures manual of every fifteen days in two out of four applicable client records reviewed.
Client #11 was admitted on December 13, 2024 and discharged on January 14, 2025. A treatment plan was completed on December 14, 2024, and the next update was due no later than December 29, 2024; however, there was no documentation that one was completed prior to the client ' s discharge.
Client #12 was admitted on January 1, 2025 and discharged on January 28, 2025. A treatment plan was completed on January 4, 2025, and the next one was due no later than January 19, 2025; however, it was completed on January 21, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
From May 9, 2025, treatment plan review compliance will be monitored daily via an online checklist. This correction was made on May 9, 2025. The Clinical Director and the Director of Quality and Compliance are responsible for this task and will report monthly to the 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 client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three applicable discharged records reviewed. The facility ' s policy and procedures manual states that follow up contacts occur at seven days, six and twelve months.
Client #14 was admitted on August 20, 2024 and discharged on September 1, 2024. There was no documentation that a seven day follow up contact occurred.
This is a repeat citation from the April 23 & 24, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Starting May 1, 2025, alumni follow-up contacts will be scheduled within 7 days, 6 months, and 12 months post-discharge. This change was enacted on May 1, 2025. The Lead Behavioral Health Technician and the Admissions Department will manage this, with tracking overseen monthly by the Director of Quality and Compliance and reports submitted to the CEO. |