INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 24, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pocono Mountain Recovery Center, LLC 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on February 24, 2026, the facility failed to keep the grounds in good repair at all times for the safety and well-being of residents, employees, and visitors.Client bedroom # 1 was observed to have two window blinds with broken and missing slats.
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Plan of Correction
The window blinds were replaced the same day immediately after the inspection. Facility Operations will continue to do weekly inspections for any and all needed repairs/replacements. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on February 24, 2026, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.Slip-resistant surfaces were not observed in room # 2,3,4,5, and 7.
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Plan of Correction
Facility Operations placed an order for non-slip mats immediately after the inspection. Mats will be installed in all client bathrooms by 03/15/26 and will be replaced when needed. Facility Operations will continue to do weekly inspections for any and all needed repairs/replacements. In addition, BHAs will continue to submit work orders to Facility Operations when a repair/replacement of something is needed. |
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 the client record, the Client Observation and Rounding policy, and other administrative documentation, the facility failed to follow its written procedures for the management of treatment/rehabilitation services.Per the Client Observation and Rounding policy, withdrawal management clients are monitored hourly. Client # 1 was admitted on 8/28/25 and discharged on 8/30/25. Documentation of hourly monitoring was not provided by the facility. The PMRC Hourly Detox Check Sheets w/ staff initials were missing from 11pm 8/28/25 through 2 pm 8/29/25.
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Plan of Correction
Leadership staff will do a review of the client observation policy with their teams to ensure that checks are done as required. In addition, to ensure that no observation sheets get lost or misfiled, a new storage system will be put in place. Observation sheets will be scanned daily into a secured shared folder for leadership staff to access as needed. |