INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18-19, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of forty-eight personnel records and the Facility ' s Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that twelve employees received the minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #7 was hired as a counselor on May 23, 2024 and was due to have the communicable disease training no later than May 23, 2025. There was no documentation for the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
Employee #8 was hired as a counselor assistant on March 27, 2023, and was promoted to counselor on November 27, 2023 and was due to have communicable disease training no later March 27, 2024. There was no documentation for the completion of the TB/STD training as of the date of the inspection.
Employee #17 was hired at the facility on September 19, 2022 and was promoted to a Behavioral Health Assistant on June 18, 2025, and was due to have communicable disease training no later than September 19, 2024. There was no documentation for the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
Employee #20 was hired as a Behavioral Health Assistant Supervisor on February 22, 2022, and was due to have the communicable disease training no later than February 22, 2024; however, the HIV/AIDS training was not completed until October 30, 2025, and the TB/STD training was not completed at the time of the inspection.
Employee #21 was hired as Behavioral Health Assistant on February 11, 2022, and was due to have the communicable disease training no later than February 11, 2022; however, the HIV/AIDS training was not completed until October 29, 2025, and the TB/STD training was not completed at the time of the inspection.
Employee #26 was hired as Behavioral Health Assistant on December 16, 2022, and was due to have the communicable disease training no later than December 16, 2024. There was no documentation for the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
Employee #28 was hired as Behavioral Health Assistant on October 23, 2023, and was due to have the communicable disease trainings no later than October 23, 2025. There was no documentation for the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
Employee #36 was hired as Behavioral Health Assistant on August 18, 2022, and was due to have the communicable disease trainings no later than August 18, 2024. There was no documentation for the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
Employee #38 was hired as Behavioral Health Assistant on August 14, 2023, and was due to have the communicable disease trainings no later than August 14, 2025. There was no documentation for the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
Employee #40 was hired as Behavioral Health Assistant on August 23, 2021, and was due to have the communicable disease trainings no later than August 23, 2023. There was no documentation for the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
Employee #41 was hired as Behavioral Health Assistant on October 23, 2023, and was due to have the communicable disease trainings no later than October 23, 2025. There was no documentation for the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
Employee #42 was hired as Behavioral Health Assistant on September 20, 2023, and was due to have the communicable disease trainings no later than September 20, 2025. There was no documentation for the completion of the TB/STD or HIV/AIDS training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Existing employees who have not yet completed these trainings will complete them by 01/31/2026 either through DDAP or onsite by the Nursing Director or designated nursing staff. New employees will be notified of these trainings upon orientation by their supervisor and via an email from the Quality Director. New employees will complete these trainings either through DDAP or onsite by the Nursing Director or designated nursing staff within one or two years, depending on the DDAP requirements for the job position. The employee's supervisor and the Quality Director will monitor for compliance and follow-up as needed. |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 10:1.
The overall facility Full Time Equivalent (FTE) is determined by dividing the total number of hours the facility devotes to their drug and alcohol clients by the facility's work week. Then, in order to obtain the facility's ratio, the total number of drug and alcohol clients is divided by the FTE.
The overall facility client to counselor ratio calculation is as follows:
200/40 = 5 (FTE); 57/5 = 11, which equals a client/counselor ratio of 11:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or the Clinical Manager will review the client/staff ratio daily. Any additional clients that would go above the limit of 10:1 will be assigned to the Clinical Manager (or Clinical Director, if needed).
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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 a review of detox client records, the facility failed to follow the written procedures for notifying the emergency contact within twelve hours of a client leaving against medical advice in one of one applicable record reviewed.
Client #5 was admitted to the inpatient non-hospital detoxification activity on October 27, 2025, and was discharged against medical advice on October 29, 2025. There was no documentation that the emergency contact was notified as of the date of the inspection.
This is a repeat citation from September 23, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or the Clinical Manager will conduct a supervision with the counselors on notification to EMCs within 12 hours of an AMA or ACA discharge. The Clinical Director and/or the Clinical Manager will review the the charts of the AMA/ACA discharged clients to ensure documentation regarding EMC notification is present in the chart.
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709.28 (c) 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.
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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 in one of twenty-one records reviewed.
Client #19 was admitted on May 6, 2025, and was still active at the time of the inspection. The record had documentation that a letter was sent to an attorney, however there was not a signed informed and voluntary consent to disclose information for the attorney in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The counselor will ask the client to sign a proper consent form for the attorney by 12/08/25. The Clinical Director (or designee) and the Risk Management Assistant will conduct an in-service by 01/31/2026 with counselors, admissions staff, and case management staff on confidentiality laws, company protocols, and proper documentation regarding consents. The Risk Management Assistant will function as a resource and as the final reviewer regarding any questions around specific record requests. The Clinical Director will conduct a supervision by 01/31/26 addressing ensuring that documentation is entered in the correct client files. The Clinical Director and/or designee will conduct monthly reviews of a random sample of charts to ensure that all needed consents and other documentation are fully and accurately completed. Any issues will be immediately addressed with the counselor and remediated within one week of the review.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in one out of twenty-one records reviewed.
Client #16 was admitted to the partial hospitalization level of care on December 30, 2024, and discharged on April 08, 2025. The record contained a consent to release information form to an outside facility signed and dated by the client on March 31, 2025, that was missing the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The counselor will ask the client to sign a proper consent forms by 12/08/25. The Clinical Director (or designee) and the Risk Management Assistant will conduct an in-service by 01/31/2026 with counselors, admissions staff, and case management staff on confidentiality laws, company protocols, and proper documentation regarding consents. The Risk Management Assistant will function as a resource and as the final reviewer regarding any questions around specific record requests. The Clinical Director and/or designee will conduct monthly reviews of a random sample of charts to ensure that all needed consents are fully and accurately completed. Any issues will be immediately addressed with the counselor and remediated within one week of the review.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the project failed to document two weekly individual counseling sessions in six of seven partial hospitalization records reviewed.
Client #15 was admitted on December 20, 2024 and was discharged on June 3, 2025. The facility only documented one individual counseling session for the weeks of December 22, 2024, through December 28, 2024, February 4, 2025 through February 10, 2025, March 03, 2025, through March 09, 2025, April 07, 2025 through April 13, 2025, and April 14, 2025 through April 20, 2025.
Client #16 was admitted on December 30, 2024 and was discharged on April 8, 2025. The facility only documented one individual counseling session for the weeks of January 5, 2025, through January 11, 2025, January 12, 2025 through January 18, 2025, January 19, 2025 through January 25, 2025, January 26, 2025 through February 01, 2025, February 09, 2025 through February 15, 2025, February 16, 2025 through February 22, 2025, and February 23, 2025 through March 01, 2025. Additionally, the facility did not document that any individual counseling sessions occurred for the week of February 02, 2025 through February 08, 2025.
Client #17 was admitted on February 28, 2025 and was discharged on April 09, 2025. The facility only documented one individual counseling session for the weeks of March 09, 2025 through March 15, 2025, and March 16, 2025 through March 22, 2025. Additionally, the facility did not document that any individual counseling sessions occurred for the weeks of March 02, 2025 through March 08, 2025, March 23, 2025, through March 29, 2025, and March 30, 2025 through April 05, 2025.
Client #18 was admitted on September 10, 2025 and was still active at the time of the inspection. The facility only documented one individual counseling session for the weeks of September 14, 2025 through September 20, 2025, November 02, 2025 through November 08, 2025, and November 09, 2025 through November 15, 2025.
Client #19 was admitted on May 06, 2025 and was still active at the time of the inspection. The facility only documented one individual counseling session for the weeks of June 22, 2025 through June 28, 2025, July 06, 2025 through July 12, 2025, July 20, 2025 through July 26, 2025, August 24, 2025 through August 30, 2025, and September 14, 2025 through September 20, 2025. Additionally, the facility did not document any individual counseling sessions for the weeks of August 10, 2025 through August 16, 2025, September 21, 2025 through September 27, 2025, September 28, 2025 through October 04, 2025, and November 09, 2025 through November 15, 2025.
Client #20 was admitted on July 23, 2025 and was still active at the time of the inspection. The facility only documented one individual counseling session for the weeks of July 27, 2025 through August 02, 2025, August 03, 2025 through August 09, 2025, September 07, 2025 through September 13, 2025, October 05, 2025 through October 11, 2025, and October 19, 2025 through October 25, 2025.
This is a repeat citation from December 04 & 05, 2023, September 23, 2024 licensing inspections and May 28, 2025 complaint investigation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and/or Clinical Manager will conduct an instructional meeting by 01/05/26 regarding the proper provision and documentation of a minimum of two individual sessions weekly. The Medical Records Clerk will conduct reviews of the records to ensure that a minimum of two individual sessions occurred and are documented weekly. These reviews already have commenced and will be ongoing. The Clinical Director and/or Clinical Manager will also conduct an additional review of the same. These reviews will commence on 01/05/26 and will be ongoing. The Clinical Director and/or Clinical Manager will immediately address any deficiencies with the counselors, with the counselors making needed corrections within one week of notification. |
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 residential client records, the facility failed to have a complete client record on an individual which included information relative to the client's involvement with the project that included follow-up information no later than 30 days following discharge, per facility policy, in two out of four applicable records reviewed.
Client #8 was admitted to the residential level of care on December 24, 2024, and was discharged on February 10, 2025. The follow-up information should have been completed by March 10, 2025; however, it was not documented until April 26, 2025.
Client #09 was admitted to the residential level of care on December 31, 2024 , and was discharged on February 10, 2025. The follow-up information should have been completed by March 10, 2025; however, it was not documented until April 26, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Supervisor of Admissions will train all case management staff, by 01/31/26, on the proper placement of the aftercare phone call and the documentation of the call (including if the call was made by the Pennsylvania Access Center). The Clinical Director will monitor monthly, at a minimum, for compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting two individual counseling sessions weekly in the partial hospitalization records was submitted and approved by the Department for the December 04 & 05, 2023, September 23, 2024, annual licensing inspections and May 28, 2025 complaint investigation. Completing and documenting two individual counseling sessions weekly in partial hospitalization records was again found to be a deficiency in the November 18-19, 2025, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance will be regularly monitored by the Medical Records Clerk and/or the Director of Clinical Services or designee. Findings will be reported to the Facility CEO and Quality Director to determine the action step for any deficiencies. |