This report is a result of an on-site licensure renewal inspection conducted on May 20, 2025, 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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Observations
Based on a review of twelve personnel records and discussion with the project director, the facility failed to ensure that six staff persons and volunteers received the minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum.
Employee #3 was hired as a medical assistant on October 21, 2019, and was still in the position at the time of the inspection. Communicable disease training was due no later than October 21, 2021; however, HIV/AIDS was not completed until April 17, 2025 and TB/STD training was not completed as of the time of the inspection.
Employee #4 was hired as a medical assistant on July 18, 2022, and was still in the position at the time of the inspection. Communicable disease training was due no later than July 18, 2024; however, there was no documentation that it was completed at the time of the inspection.
Employee #5 was hired as a medical receptionist on April 4, 2022, and was still in the position at the time of the inspection. Communicable disease training, specifically, STD/TB training was due no later than April 4, 2022; however, there was no documentation that it was completed at the time of the inspection.
Employee #9 was hired as a certified medical specialist on May 02, 2022 and was still in the position at the time of inspection. Communicable disease training, specifically, STD/TB training was due no later than May 02, 2024; however, there was no documentation that it was completed at the time of the inspection.
Employee #10 was hired as a care coordinator on April 22, 2014 and was still in the position at the time of inspection. Communicable disease training, specifically, HIV/AIDS training was due no later than April 22, 2016; however, there was no documentation that it was completed at the time of the inspection.
Employee #12 was hired as a center manager on December 19, 2022 and was still in the position at the time of inspection. Communicable disease training was due no later than December 19, 2024; however, there was no documentation that it was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 23, 2024 licensing inspection.
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Plan of Correction
All current PA employees will be trained on the following Communicable Diseases of HIV/AIDS and TB/STD through DDAP directly.
The locations Center Manager will be responsible for ensuring all staff receive the required training by end of Q3 9/30/2025.
All new employees will be trained within their 1st or 2nd year of employment via DDAP directly. The locations Center Manager will be responsible for tracking completing of these trainings in the required timeframe. 6-month audits on required trainings will be conducted by the Learning and Development team. |
Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent form the client prior to disclosing information in one out of seven records reviewed.
There was no consent to release information form for the funding source. The facility confirmed billing occurred.
Client #6 was admitted on April 19, 2024, and discharged on September 11, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate's Learning and Development department will complete a training with all staff on the proper completion of the consent for funding source and ensuring documentation is placed in the patient chart. This training will be completed on 7/10/2025.
Ongoing auditing for correct completion of a funding source release will be completed by the programs Center Manager on a 6month basis to ensure compliance with this regulation.
CleanSlates billing department received Instruction on 6/9/2025 to check patients charts for funding releases prior to billing for services. CleanSlates Billing Manager will complete a quarterly audit on this process to ensure compliance. |