INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2022 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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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a reconsideration request opportunity during the termination in one out of one applicable record reviewed.
Client #6 was admitted on October 18, 2021 and was discharged on December 29, 2021.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
RIGHT TO REQUEST RECONSIDERATION OF INVOLUNTARY DISCHARGE/TERMINATION FROM PROGRAM
To be in compliance with regulation 709.33(a), Clinical staff must request all newly admitted clients to read and sign the client rights and responsibilities form, which states that individuals have the right "to request reconsideration of a decision terminating treatment." The Facility Director and Compliance Officer will audit all newly admitted charts to ensure that standard 709.33(b) is properly followed. Counselors who are found non-compliant with this regulation will receive additional assistance or individual direction from the Associate Clinical Supervisor or Facility Director.
The Facility Director requested changes to be made with the Electronic Medical Records Company to add the reconsideration request opportunity notification in our EMR system. The notification will be active by May 26, 2022. |
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 conduct a follow up in one out of three applicable records reviewed.
Client #6 was admitted on October 18, 2021 and was discharged on December 29, 2021. The client record did not contain documentation of a follow up.
The finding was reviewed with the facility staff during the inspection process.
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Plan of Correction
The Facility Director and Associate Clinical Supervisor will monitor our Discharge Coordinator's follow-up contact log on a weekly basis. The Facility Director provided the Discharge Coordinator with a report that will help her better manage where she is at with her calls on a monthly basis so that all clients receive a treatment follow-up phone call as scheduled in our protocol. |