INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2026, 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 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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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the project failed to offer the client a copy of informed and voluntary consent to disclose information forms in seven of seven records reviewed.
The facility failed to document that a copy was offered for all informed and voluntary consent to disclose information forms in the seven client records that were reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/30/2026, the Clinical Director and IT staff member met with the EMR representative to review and correct the electronic consent forms for all informed and voluntary consents. The forms were updated to include a required checkbox confirming that the client was offered a copy of the consent forms, and cannot be finalized unless the checkbox is completed.
On 5/1/2026, the Clinical Director met with all clinical staff and provided education regarding DDAP requirements for informed and voluntary consent to disclose information forms, including the requirement to document that clients were offered copies of completed consent forms.
Effective 4/30/2026, all staff will utilize the updated electronic consent forms. The Clinical Director will conduct weekly audits of client records for ongoing compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 1 was admitted to the residential program on September 25, 2025, and was involuntarily discharged on November 13, 2025. The record did not contain documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate the client ' s treatment at the project.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will document in the EMR and notify clients in writing of the reason for administrative discharge and their right to appeal. The Clinical Director will conduct weekly audits to ensure ongoing compliance. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include verification that any work done by the client at the project is an integral part of their treatment and rehabilitation plan in seven of seven records reviewed.
Client # 1 was admitted to the residential program on September 25, 2025, and was discharged on November 13, 2025. The individual treatment and rehabilitation plan completed on September 29, 2025, did not include verification that work done by the client at the project is an integral part of treatment; however, documentation in client handbook contained evidence that clients are required to do work at the facility.
Client # 2 was admitted to the residential level of care on November 29, 2025, and was discharged on December 14, 2025.The individual treatment and rehabilitation plan completed on December 1, 2025, did not include verification that work done by the client at the project is an integral part of treatment; however, documentation in client handbook contained evidence that clients are required to do work at the facility.
Client # 3 was admitted to the residential level of care on August 26, 2025, and was discharged on October 9, 2025. The individual treatment and rehabilitation plan completed on August 27, 2025, did not include verification that work done by the client at the project is an integral part of treatment; however, documentation in client handbook contained evidence that clients are required to do work at the facility.
Client # 4 was admitted to the residential level of care on December 18, 2025, and was discharged on February 2, 2026 The individual treatment and rehabilitation plan completed on December 21, 2025 did not include verification that work done by the client at the project is an integral part of treatment; however, documentation in client handbook contained evidence that clients are required to do work at the facility.
Client # 5 was admitted to the residential level of care on February 19, 2026, and was active at the time of licensing process. The individual treatment and rehabilitation plan completed on February 19, 2026, did not include verification that work done by the client at the project is an integral part of treatment; however, documentation in client handbook contained evidence that clients are required to do work at the facility.
Client # 6 was admitted to the residential level of care on March 5, 2026, and was active at the time of licensing process. The individual treatment and rehabilitation plan completed on March 6, 2026, did not include verification that work done by the client at the project is an integral part of treatment; however, documentation in client handbook contained evidence that clients are required to do work at the facility.
Client # 7 was admitted to the residential level of care on March 4, 2026, and was active at the time of licensing process. The individual treatment and rehabilitation plan completed on March 4, 2026, did not include verification that work done by the client at the project is an integral part of treatment; however, documentation in client handbook contained evidence that clients are required to do work at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/7/2026, the Clinical Director and IT staff met and updated the treatment plan templates to include objectives and interventions that will automatically populate within the treatment plans. Counselors will continue to identify and document treatment plan goals related to work, employment, and daily chores as appropriate to the client's needs. The Clinical Director will audit weekly for ongoing compliance. |