INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 3-6, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site 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. The following deficiencies were identified during this investigation:
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Plan of Correction
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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 the review of the facility's policy and procedure manual, staff interviews and client records, the facility failed to adhere to written procedures for the management of treatment/rehabilitation services for clients.
The facility's "Patient Monitoring Policy" notes that high risk patients those with a "history of seizures, or delirium tremens, unstable vital signs, polysubstance abuse" will have their vital signs checked every "1 to 2 hours."
Client # 1 was admitted to detox on April 27, 2026, and discharged on May 7, 2026. This client had a history of seizures and was deemed, by facility policies, high risk. A review of the client's medical record revealed that on May 5, 2026, vital signs were completed at 20:50hrs, the next vital signs were documented on May 6, 2026, at 08:15 hrs. Additionally the next vital sign check was documented on May 6,2026,6 at 15:22 hrs.
Additionally, the facilities "Treatment Timeframes" policy notes "case consultations: conducted during clinical meetings. Each patient must have a formal case review 15 days from admission date."
Client #2 was admitted May 27, 2026, and discharged July 6, 2026. A case consultation was due no later than June 11, 2026; howoever, the inital case consultation was completed June 24. 2026.
Further, the facility's "Urine Drug Screen and Breathalyzer Upon Admission" policy notes that " testing shall occur as soon as possible upon arrival and prior to full admission when feasible." Staff interviews revealed that urine samples are collected but are not always tested.
Finally, the facility's "Grievance Policy" notes that "the grievance will be investigated and responded to within five to seven day." DDAP staff reviewed the greivance log and there were several grievances that were submitted; however, there was no documentation of a response from the facility.
These findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Facility will re-educate the medical and nursing staff on Policy: Patient Monitoring Policy by 9.23.2026 to ensure all medical and nursing staff understand and agree to comply with the patient monitoring for high-risk patients with a history of seizures, or delirium tremens, unstable vitals and polysubstance abuse, that is in place via facility policy. Facilities Quality Improvement/Risk Management staff will complete weekly audits for a minimum of 90 days to ensure compliance is held. When compliance is deemed consistent, audits will decrease to bi-weekly.
Facility will re-educate the clinical staff on Policy: Treatment Timeframes Policy by 9.23.206 to ensure all clinical staff understand and agree to comply with the treatment timeframes, including timeframe for case consultations to be completed. Clinical Director will complete weekly audits for a minimum of 90 days to ensure compliance is held. When compliance is deemed consistent, audits will decrease to bi-weekly.
Facility will re-educate the medical and nursing staff on Policy: Urine Drug Screen and Breathalyzer Upon Admission Policy by 9.23.2026 to ensure all medical and nursing staff understand and agree to comply with the Urine Drug Screen and Breathalyzer Upon Admission Policy that is in place via facility policy. Facility will reiterate also the importance of ensuring the samples that are collected are sent out for testing, per policy. Facilities Quality Improvement/Risk Management staff will complete weekly audits for a minimum of 90 days to ensure compliance is held. When compliance is deemed consistent, audits will decrease to bi-weekly.
Facility will re-educate the Leadership Team Staff Policy: Grievance Policy by 9.23.2026 to ensure all Leadership Team Staff understand and agree to comply with the Grievance Policy, including timeframe for Grievances to be investigated and responded to, which is 5-7 days. The Executive Leadership Team and Service and Advocacy Coordinator will develop and maintain a Compliance tracker of all grievances filed, the date filed, the date of investigation conclusion and the date the response was provided to the individual who filed the grievance. The Service and Advocacy Coordinator will complete weekly audits for a minimum of 90 days to ensure compliance is held. When compliance is deemed consistent, audits will decrease too bi-weekly.
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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 staff interviews and an inspection of the medical building the facility failed to ensure that outdated drugs are removed.
The facility's "Medication Control and Accountability Policy: notes that "expired or discontinued medications will be removed promptly" the facility defines promptly as "within thirty days of client discharge."
DDAP staff inspected the medical building, specifically the medication cabinet. DDAP staff observed that medication from a client that had been discharged over thirty days ago was still being held in the medications cabinet.
This finding was reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Facility will re-educate the medical and nursing staff on Policy: Medication Control and Accountability Policy by 9.23.2026 to ensure all medical and nursing staff understand and agree to comply with the Medication Control and Accountability Policy that is in place via facility policy. Facility will separate current patient medications from discharged patient medications and properly store them in separate areas. Facilities Quality Improvement/Risk Management staff will complete monthly audits on a recurring basis to ensure compliance is held. The Quality Improvement/Risk Management staff will ensure that all medications are disposed of within 30 days of any/all patient's discharges. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days.
During the client file review, it was observed by DDAP staff that on May 6, 2026, Client #1, who was admitted on April 27, 2026, and discharged on May 7, 2026, reportedly had a medical issue which required nursing staff to contact EMS/911. There was no record at the facility or in PACTs to verify that this incident had been reported.
These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
Facility CEO, Chief Nursing Officer (CNO) and the Director of Medical Services have assumed responsibility for ensuring all Unusual Incident Reports are submitted on the DDAP portal within 3 business days following the incident through the ERS system. CNO and/or Director of Medical Services will report all Unusual incidents verbally or via email to the CEO. CEO will submit the Unusual Incidents on the ERS portal. In the event the CEO is unavailable for 3 or more business days, the CNO or Director of Medical Services will submit the indicant on the ERS portal. |