INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CleanSlate Medical Group of Pennsylvania, 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to complete an assessment of staff training needs for the current training year, January 31, 2024, through December 31, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that an assessment of Staff training needs is completed for each training year as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for completing an annual assessment of Staff training needs in collaboration with the Project Director & Organizational Leadership.
The annual Staff training needs assessment for training year 2024 will be completed by the end of Q2 2024.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop an overall plan for addressing staff training needs for the current training year, January 31, 2024 through December 31, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that an overall Staff training plan is completed for each training year as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for establishing an annual overall Staff training plan in collaboration with the Project Director & Organizational Leadership.
The annual overall Staff training plan addressing assessed Staff training needs for training year 2024 will be completed by the end of Q2 2024.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility's staff development program and employee training records, the facility failed to develop a mechanism to collect feedback on completed trainings.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that a mechanism to collect feedback on completed training is established & implemented as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for establishing & implementing the completed training feedback collection mechanism in collaboration with the Project Director & Organizational Leadership.
The feedback collection mechanism for completed training will be established & implemented by the end of Q2 2024.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's staff development program, the facility failed to failed to complete an annual evaluation of the overall training plan for training year January 31, 2023 through December 31, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that an annual evaluation of the overall Staff training plan is conducted for each training year as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for conducting an annual evaluation of the overall Staff training plan in collaboration with the Project Director & Organizational Leadership.
The annual evaluation of the overall Staff training plan for training year 2024 will be completed by the end of Q4 2024.
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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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that facility staff received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Staff #2 was hired as a counselor on October 31, 2022 and was due to have the communicable disease trainings no later than October 31, 2023. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDs and the TB/STD trainings.
Staff #4 was hired as the facility director on April 23, 2023, and was due to have the communicable disease trainings no later than April 23, 2024. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and TB/STD trainings.
Staff #5 was hired as a medical receptionist on April 4, 2022, and was due to have the communicable disease trainings no later than April 4, 2024. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and TB/STD trainings.
Staff #6 was hired as a medical receptionist on July 6, 2020, and was due to have the communicable disease trainings no later than July 6, 2022. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and TB/STD trainings.
Staff #7 was hired as a a certified recovery specialist on May 2, 2022, and was due to have the communicable disease trainings no later than May 2, 2024. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and TB/STD trainings.
Staff #8 was hired as a care coordinator on July 15, 2019, and was due to have the communicable disease trainings no later than July 15, 2021. As of the date of the inspection, there was no documentation in the personnel file of the completion of the TB/STD training.
Staff #9 was hired as a certified recovery specialist on September 23, 2019, and was due to have the communicable disease trainings no later than September 23, 2021. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and TB/STD trainings.
Staff #10 was hired as a medical assistant on October 21, 2019, and was due to have the communicable disease trainings no later than October 21, 2021. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD trainings.
Staff #11 was hired as a medical assistant on September 28, 2015, and was due to have the communicable disease trainings no later than September 28, 2017. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD trainings.
Staff #12 was hired as a medical assistant on October 4, 2021, and was due to have the communicable disease trainings no later than October 4, 2023. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and TB/STD trainings.
Staff #13 was hired as a care coordinator on April 22, 2019 and was due to have the communicable disease trainings no later than April 22, 2021. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS and the TB/STD trainings.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training and education to ensure that all new employees will be required to complete the Communicable Disease trainings. Non-Clinical staff within their 1st 2 years of employment and Clinical staff within their 1st year of employment.
The CleanSlate Learning &Development Department team along with the Project Director and Operational Leadership will be responsible for tracking the completion of these required trainings on a yearly basis.
All new staff will have the Communicable Disease trainings listed on their Annual Training plan, completed by the end of Q4 2024.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Staff #3 was hired on December 11, 2023, as a counselor and was still in the position as of the date of the inspection. There was no documentation available to verify that Staff #3 had received this training.
This finding was reviewed with the facility during the inspection process.
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Plan of Correction
CleanSlate will ensure its Learning & Development policies & procedures for Personnel training & education include instruction to Staff on the use of a fire extinguisher upon Staff employment with the instruction completion being documented in Staff training records.
The CleanSlate Learning & Development Department will be responsible for ensuring that all Staff are assigned & complete training on the use of a fire extinguisher upon employment in collaboration with the Project Director & Organizational Leadership.
Staff training plans for training to be completed initially upon employment that include training on the use of a fire extinguisher shall be established, implemented & assigned to all CleanSlate Staff moving-forward by the end of Q2 2024. In addition, any established Staff that have not completed this training shall be assigned for completion within this timeframe.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Staff #3 was hired on December 11, 2023, as a counselor and was still in the position as of the date of the inspection. There was no documentation available to verify that Staff #3 had received this training.
This finding was reviewed with the facility during the inspection process.
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Plan of Correction
The CleanSlate Learning & Development Department will be responsible for ensuring that all Staff are assigned & complete training on Fire Safety which covers the essential topics to assist with what to do in case of a fire, including workplace fire hazards, using fire extinguishers, and RACE.
CleanSlate Operations will be responsible for training all new personnel during Orientation on emergency exit plans, location of fire extinguishers, and local emergency contacts.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the January 23, 2023, through May 10, 2024, fire drill logs the facility failed to set off the fire alarm or smoke detector during each fire drill.
The facility reported on each of the seventeen fire drills completed that a verbal command or a phone simulation was executed in lieu of sounding the alarm or smoke detector.
The facility does not currently have an exemption waiver in place for this regulator requirement.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will be submitting an exception request for this regulation due to the facility being located in a suite within a large office building.
CleanSlate operational leadership will continue to conduct unannounced fire drills on a monthly basis with a hand held alarm that can be heard within the suite. In addition to the hand held alarm, leadership will also use a voice command to inform the office of a fire drill.
Operational Leadership will document completed drills via a Fire Drill log kept at the center. Operational Leadership will also submit to the company's Health and Safety committee to track for the company to ensure that the handheld alarm is being utilized.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facilities policy and procedure manual and interviews with the facility staff, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Policy & Procedure Development & Implementation include documentation of the Project Director's annual preparation, review, update & signature of the Project's policies & procedures.
The CleanSlate Project Director will be responsible for ensuring the documented annual completion for preparation, review, update & signature of the Project's policies & procedures in collaboration with Organizational Leadership.
The documented annual completion for preparation, review, update & signature of the Project's policies & procedures for 2024 will be completed by the end of Q2 2024.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures of all the required client rights, including a client receiving care or treatment under section 7 of the act (71 P.S. & 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason on treatment.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures to include documentation of all the required client rights, including the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in four out of seven records. The policy does not include color and marital status.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures to inform the client of all their rights. The client rights form given to the client did not identify that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record in seven out of seven records.
This is a repeat citation from the July 15, 2023 licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to appeal a decision limiting access to their records.
This is a repeat citation from the July 15, 2023 licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: Clients have the right to appeal a decision limiting access to their records to the director. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document that disclosure to the client of criteria for admission, treatment, completion and discharge had taken place in five out of seven records reviewed.
Client #1 was admitted on November 29, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on February 29, 2024, and was still active at the time of the inspection.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024.
Client #7 was admitted on January 3, 2024, and was discharged on May 3, 2024.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient intake & orientation education includes the following information: Disclosure to the client of criteria for admission, treatment, completion and discharge. This information will also be included in the CleanSlate Patient Handbook & a Patient's receipt of the Patient Handbook shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that the Patient Handbook is provided to all Patients & documented written acknowledgement that each Patient has been offered &/or provided a copy of the Patient Handbook is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be offered &/or provided with a copy of the Patient Handbook & be requested to sign an acknowledgement of receipt form as written documentation that they have been offered &/or received the Patient Handbook. This process shall be completed by the end of Q2 2024. All Patients will be offered &/or provided the Patient Handbook & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document that client orientation had taken place, including project policies, in five out of seven records reviewed.
Client #1 was admitted on November 29, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on February 29, 2024, and was still active at the time of the inspection.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024.
Client #7 was admitted on January 3, 2024, and was discharged on May 3, 2024.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient intake & orientation education includes familiarization with the following information: Project policies. This information will also be included in the CleanSlate Patient Handbook & a Patient's receipt of the Patient Handbook shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that the Patient Handbook is provided to all Patients & documented written acknowledgement that each Patient has been offered &/or provided a copy of the Patient Handbook is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be offered &/or provided with a copy of the Patient Handbook & be requested to sign an acknowledgement of receipt form as written documentation that they have been offered &/or received the Patient Handbook. This process shall be completed by the end of Q2 2024. All Patients will be offered &/or provided the Patient Handbook & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document that client orientation had taken place, including hours of operation, in five out of seven records reviewed.
Client #1 was admitted on November 29, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on February 29, 2024, and was still active at the time of the inspection.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024.
Client #7 was admitted on January 3, 2024, and was discharged on May 3, 2024.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient intake & orientation education includes familiarization with the following information: Hours of operation. This information will also be included in the CleanSlate Patient Handbook & a Patient's receipt of the Patient Handbook shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that the Patient Handbook is provided to all Patients & documented written acknowledgement that each Patient has been offered &/or provided a copy of the Patient Handbook is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be offered &/or provided with a copy of the Patient Handbook & be requested to sign an acknowledgement of receipt form as written documentation that they have been offered &/or received the Patient Handbook. This process shall be completed by the end of Q2 2024. All Patients will be offered &/or provided the Patient Handbook & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document that client orientation had taken place, including fee schedule, in five out of seven records reviewed.
Client #1 was admitted on November 29, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on February 29, 2024, and was still active at the time of the inspection.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024.
Client #7 was admitted on January 3, 2024, and was discharged on May 3, 2024.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient intake & orientation education includes familiarization with the following information: Fee schedule. This information will also be included in the CleanSlate Patient Handbook & a Patient's receipt of the Patient Handbook shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that the Patient Handbook is provided to all Patients & documented written acknowledgement that each Patient has been offered &/or provided a copy of the Patient Handbook is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be offered &/or provided with a copy of the Patient Handbook & be requested to sign an acknowledgement of receipt form as written documentation that they have been offered &/or received the Patient Handbook. This process shall be completed by the end of Q2 2024. All Patients will be offered &/or provided the Patient Handbook & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document that client orientation had taken place, including services provided, in five out of seven records reviewed.
Client #1 was admitted on November 29, 2023, and was still active at the time of the inspection.
Client #2 was admitted on February 29, 2024, and was still active at the time of the inspection.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024.
Client #7 was admitted on January 3, 2024, and was discharged on May 3, 2024.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient intake & orientation education includes familiarization with the following information: Services provided. This information will also be included in the CleanSlate Patient Handbook & a Patient's receipt of the Patient Handbook shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that the Patient Handbook is provided to all Patients & documented written acknowledgement that each Patient has been offered &/or provided a copy of the Patient Handbook is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be offered &/or provided with a copy of the Patient Handbook & be requested to sign an acknowledgement of receipt form as written documentation that they have been offered &/or received the Patient Handbook. This process shall be completed by the end of Q2 2024. All Patients will be offered &/or provided the Patient Handbook & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document that clients had consented to participate in treatment in seven out of seven records reviewed.
Client #1 was admitted on November 29, 2023, and was still active at the time of the inspection.
Client # 2 was admitted on February 29, 2024, and was still active at the time of the inspection.
Client #3 was admitted on March 28, 2024, and was discharged on April 24, 2024.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection.
Client #5 was admitted on February 21, 2024, and discharged on March 27, 2024.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024.
Client #7 was admitted on January 3, 2024, and was discharged on May 3, 2024.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
CleanSlate will update and revise its policies & procedures for Patient intake & Admission education to include obtaining each patient's Consent to participate in treatment; documentation of a signed Consent to Counseling Treatment will be maintained in each client's record.
CleanSlate's Operational and Behavioral Health Leadership will be responsible for ensuring Consent to treatment is obtained from each patient and a corresponding signed Consent to Counseling Treatment is maintained in the client's record.
The revised Policies and Procedures for Intake and Admission to include obtaining consent to counseling treatment shall be established and educated for implementation by the end of Q2 2024.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within two weeks following the intake session.
Client #1 was admitted on November 29, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 13, 2023; however, the treatment plan was completed February 21, 2024.
Client #3 was admitted on March 28, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 11, 2024; however, the treatment plan was completed April 25, 2024.
Client #5 was admitted on February 21, 2024, and was discharged March 27, 2024. A comprehensive treatment plan was due no later than March 6, 2024; however, there was no treatment plan documented in the client record.
Client #7 was admitted on January 1, 2024, and was discharged May 3, 2024. A comprehensive treatment plan was due no later than January 15, 2024; however, the treatment plan was completed March 27, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CleanSlate will update & revise its policies & procedures for Patient treatment plans to include ensuring a documented individual treatment plan is developed with each Patient. The treatment plan will be initiated by the third-visit. Should the treatment plan be completed at a date other than the specified timeframe, documentation for such delay will be noted in the Patient's record.
CleanSlate Medical & Behavioral Health Leadership will be responsible for ensuring that treatment plans are completed & documented timely according to CleanSlate policies & procedures in collaboration with the Project Director & Organizational Leadership.
The revised policies & procedures for completion of a Patient's documented treatment plan shall be established & educated for implementation by the end of Q2 2024.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of residential client records, the facility failed to document type and frequency and rehabilitation services on individual treatment plans in two out of six applicable records reviewed.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 11, 2024, did not document type or frequency of treatment services.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024. The comprehensive treatment plan, completed March 11, 2024, did not document type or frequency of treatment services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CleanSlate will update & revise its policies & procedures for Patient treatment plans to include ensuring a documented individual treatment plan is developed with each Patient and includes type and frequency of rehabilitation services.
CleanSlate Medical & Behavioral Health Leadership will be responsible for ensuring that treatment plans are completed & documented timely according to CleanSlate policies & procedures in collaboration with the Project Director & Organizational Leadership.
The revised policies & procedures for completion of a Patient's documented treatment plan shall be established & educated for implementation by the end of Q2 2024.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of residential client records, the facility failed to document proposed type of support service on individual treatment plans in two out of six applicable records reviewed.
Client #4 was admitted on March 28, 2024, and was still active at the time of the inspection. The comprehensive treatment plan, completed April 11, 2024, did not document client support services.
Client #7 was admitted on January 3, 2024, and was discharged on May 3, 2024. The comprehensive treatment plan, completed March 27, 2024, did not document client support services.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CleanSlate will update & revise its policies & procedures for Patient treatment plans to include ensuring a documented individual treatment plan is developed with each Patient and includes proposed types of support services.
CleanSlate Medical & Behavioral Health Leadership will be responsible for ensuring that treatment plans are completed & documented timely according to CleanSlate policies & procedures in collaboration with the Project Director & Organizational Leadership.
The revised policies & procedures for completion of a Patient's documented treatment plan shall be established & educated for implementation by the end of Q2 2024.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document the review of treatment and rehabilitation plans every sixty days in two of two applicable client records.
Client # 1 was admitted on November 29, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was documented in the client record on February 21, 2024. An updated treatment plan was due no later than April 21, 2024; however, the updated treatment plan was completed May 1, 2024.
Client #2 was admitted on February 28, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was documented in the client record on February 28, 2024. An updated treatment plan was due no later than April 28, 2024; however, the updated treatment plan was completed May 7, 2024.
This is a repeat citation from the July 15, 2023 licensing renewal inspection.
These findings were reviewed with the facility during the inspection process.
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Plan of Correction
CleanSlate will update & revise its policies & procedures for Patient treatment plans to include ensuring individual treatment plan reviews & updates are completed & documented for each Patient at least every 60-days.
CleanSlate Medical & Behavioral Health Leadership will be responsible for ensuring that treatment plan reviews & updates are completed & documented timely according to CleanSlate policies & procedures in collaboration with the Project Director & Organizational Leadership.
The revised policies & procedures for completion & documentation of reviews & updates for Patient treatment plans shall be established & educated for implementation by the end of Q2 2024.
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709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on a review of the client records the facility failed to document a discharge summary at the time of discharge, as per the facility policy, in two of four applicable client records.
Client #5 was admitted on February 21, 2024, and was discharged on March 27, 2024. There was no discharge summary documented in the client's record.
Client #6 was admitted on February 26, 2024, and was discharged on April 23, 2024. There was no discharge summary documented in the client's record.
This is a repeat citation from the July 15, 2023 licensing renewal inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
CleanSlate will update & revise its policies & procedures for Patient discharges to include ensuring a documented discharge summary is completed within 30-calendar days of the Patient's discharge.
CleanSlate Medical & Behavioral Health Leadership will be responsible for ensuring that discharge summaries are completed & documented timely according to CleanSlate policies & procedures in collaboration with the Project Director & Organizational Leadership.
The revised policies & procedures for completion of a Patient's documented discharge summary shall be established & educated for implementation by the end of Q2 2024.
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