INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on October 21-24, 2019, by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, Clear Day Treatment of Westmoreland, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
|
Observations
The facility failed to hire staff in sufficient numbers to insure efficient and safe operation of all of the services provided by the project
According to interviews with staff and clients the techs are reported to be working in both the detox and the rehab on the same shift, at times, due to a shortage of techs. This has caused a lapse in some procedures being carried out, such as intake or room searches, client monitoring and hourly checks, due to not enough staff on-site.
This information was shared with the facility staff in order to address the staffing deficiency.
|
Plan of Correction
The Executive Director has initiated steps to increase recovery technician staffing in detox and the rehab. On 11/4/2019 the Executive Director placed new ads with Indeed, Craig's List and Zip Recruiter. The goal is to have 4-5 Recover Techs on every shift by December 1, 2019. On November 1, 2019 we added 2 new Recovery Techs to the schedule. We also hired 2 techs that will begin on December 1, 2019. Additionally we have offered overtime to all the Recovery Techs. The counselors have been giving the opportunity to serve as Recovery Techs on their off time at their same rate of pay. Also we work with a temp agency that will refer temp Recovery Techs to Clear Day. The Executive Director along with Tech Manager will conduct interviews ongoing to keep the appropriate Tech staffing compliment. The long term goal is to have 5 Techs on duty at all times. |
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.
|
Observations
The facility failed to keep the facility safe at all times.
There were plastic bags and a pair of pants lodged behind the clothes dryer in the laundry area, which created a fire hazard.
This information was shared with the facility staff in order to address the hazardous condition.
|
Plan of Correction
On 7/5/2019The staff at Clear Day were retrained regarding the expectation for the laundry room. The Recovery Tech Supervisor or their designee is responsible for ensuring that there is no debris on top of or behind the washers and dryers. The Recovery Technician Supervisor will check daily to ensure Clear Day is compliant with 705.2 (2) Done 11-6-19 |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
The facility failed to ensure the confidentiality of counseling sessions.
The lounge area on the female resident wing had a video camera mounted on the ceiling. According to facility staff the lounge area is also utilized for conducting group counseling sessions.
Additionally, there were two cameras in the dining area which was being utilized to conduct a group session during the physical plant inspection.
|
Plan of Correction
On 11/7/2019 the Executive Director had cameras removed in all areas where group counseling is taking Place. Six cameras were removed from the facility on 11/7/2019. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
The facility failed to ensure that all heaters were permanently mounted.
There was a space heater in the counseling office next to the men ' s staff bathroom across from the storage area.
This information was shared with the facility staff in order to address the hazardous condition.
|
Plan of Correction
The Clinical Director met with all counselor and medical staff regarding 705.8 LICENSURE (Heating and cooling regulations). The Staff at Clear Day has been made aware, no free-standing portable heater are ever permitted in the facility. The Clinical Direction will check all office spaces weekly to ensure Clear Day is compliant with 705.8. (2) Done on 10-18-19 |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
|
Observations
The facility failed to maintain two exits from every floor, including the basement.
During the physical plant inspection facility staff were observed bringing discharged client files to the basement directly below the detox area. It was observed and confirmed with staff that this area has only one exit.
This information was shared with the facility staff in order to address the condition.
|
Plan of Correction
On November 4, 2019,the Executive Director Collected all basement keys from staff and returned them to the owner of the building. Additionally ON 11/6/2019 the Executive Director, in staff meeting, informed all employees that the basement is a restricted area. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
|
Observations
The facility failed to provide a written job description for the position of Recovery Technician that corresponds to the actual duties of that position.
According to interviews with staff the duties for the Recovery Technician include client monitoring, routine checks of client location, cleaning and resetting rooms after client discharge, conducting searches at intake, orienting clients at intake, transporting clients, and conducting life-skills groups.
The supplied job description for the Recovery Technician does not list any of the above tasks or responsibilities and contains duties that are not commensurate with the level of care being provided at the facility, such as " performing sterile dressing changes " , " assistance with feeding tubes, performance of basic nursing care and answering patient call lights " .
Facility staff confirmed that this job description does not capture the duties of the position for which it was created.
|
Plan of Correction
On 11/4/19 Recovery Technician Supervisor met with all Recovery Technicians regarding their updated job description. The new job descriptions is congruent with all daily/weekly task. Technician Supervisor will check weekly to ensure Clear Day is compliant with 709.26 (c) Done 11-6-19 |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
The facility failed to secure client records within locked storage containers.
During the physical plant inspection discharged client files were observed in boxes on shelves in the basement. Although the area was locked there were other items being stored in the basement, such as paint and supplies for the facility, which would necessitate these records also being securely stored in this area.
Additionally, there were unsecured client records on the floor of the counseling office at the end of the hall on the right side next to the dining area.
This information was shared with the facility staff in order to address the condition.
|
Plan of Correction
Clear Day has a policy is that all patient records are kept confidential and recorded in our electronic patient record system, SAMMS. The Clinical Director will assure that counselors record patient information into SAMMS. Any handwritten documentation regarding patient information will be maintained in a locked storage container. The Clinical Director will monitor counselors' offices weekly ensuring no patient information is visible or accessible. On November 4, 2019 the Executive Director removed all patient's records from the basement storage and relocated them to his office in locked filing cabinets behind a locked door. Additionally, on November 4, 2019,the Executive Director collected all basement keys from staff and returned them to the owner of the building. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
|
Observations
The facility failed to enforce their policy regarding misuse of drugs.
According to interviews with clients and staff, clients were found to be diverting medication in order to sell or trade it with other patients; nursing staff procedure is to observe clients when medication is administered and look in the cheeks and under the tongue of the individual to ensure proper ingestion of medication and to help prevent this type of diversion, however it was reported during the investigation that clients were still able to divert medication because some staff were not following this procedure.
|
Plan of Correction
Clear Day has a medication administration policies in place for correct medication administration. ADON retrained nursing staff on administration of medication and how to properly check patients mouths to be sure medication is being properly ingested and not being diverted. The ADON will watch nurses administer medications periodically to ensure medication is being administered correctly. Completed on 11-6-19 |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
|
Observations
The facility failed to enforce their policy regarding involuntary termination.
Facility policy states that clients are to be discharged when ' The patient has committed or threatened to commit acts of physical violence while he/she is CDT patient .... " , however it was reported by staff and by residents that individuals are permitted to remain at the facility despite making threats to staff and/or other residents.
|
Plan of Correction
The policy will not be revised. Instead staff will be held accountable to enforce the policy. Clear Day Treatment will review the policy as written to assure it meets standard operating procedures that assure safety, well-rounded and sound judgment. The executive director will conduct a forum with staff on 11/13/19 to hear staff concerns and to revisit the policy as written. The focus of this forum will be to reiterate the importance of staff sense of safety and well-being while working in this facility. When a credible threat is made toward staff, the patient will be terminated from this facility immediately. The patient will sit with their counselor to receive a referral to another facility, if accepted by patient. The executive director and/or clinical director will conduct a thorough debriefing with that staff to assure an understanding of the resolution and restored sense of safety.
All current patients provided with a review of the involuntary termination policy related to threats made to other peers. Additionally, Clear Day Treatment will review this involuntary termination policy with each new patient, as part of their orientation the first day of treatment/detox. Review of this policy will be verified by the patient's signature of receipt of the CDT Patient Handbook. If a patient threatens a peer or staff member, that patient will be terminated immediately from this facility. According to the written policy ? The patient may receive opportunity through their counselor to continue treatment at another facility if appropriate. A limited debriefing will occur (safeguarding confidentiality) with the Clinical Director and/or that patient's counselor to assure a sense of safety in the facility
|
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
|
Observations
The facility failed to properly label stored food to ensure safety of residents.
The refrigerator in the dining area contained unlabeled and undated generic containers of salad dressing and contained unlabeled and undated containers of unidentified food as well as plates of leftover food which were not dated.
This information was shared with the facility staff in order to address the hazardous condition.
|
Plan of Correction
On 11/4/2019 Clear Day's Executive Director spoke with the food service contractor to inform him that all food items must be dated before being left with our facility. Specially, I informed the food service contractor that all generic container must labeled with the name, date and time.. Additionally, I have instructed staff to discard any unlabeled or undated food items left on site. Any saved left over food item will be labeled with the name, date and time before it is placed in the refrigerator. Left over food items will be discarded after 24 hours. |