INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Day Treatment of Westmoreland 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of six months of supervision for a counselor assistant with a bachelor's degree.
Employee # 6 was hired as a counselor assistant on August 16, 2021 and was still in this position at the time of the inspection. Supervision notes were provided weekly from August 20, 2021 until December 10, 2021. Supervision was due to continue until February 16, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan for correction: Clear Day's Clinical Director and Clinical Supervisor will be conducting weekly supervision for all counselors according to the level of education and work experience required by Pennsylvania Licensure The Executive Director is responsible for ensuring the corrective action(s) are implemented. |
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 employee's #7, #8, #9, #10 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.
Employee #7 was hired as a recovery technician on July 15, 2019 and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than July 15, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #8 was hired as a recovery technician on December 3, 2019 and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than December 3, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #9 was hired as a recovery technician on August 12, 2019 and was still in this position at the time of the inspection. Employee # 9 was due to have the communicable disease trainings no later than August 12, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #10 was hired as a recovery technician on September 30, 2019 and was still in this position at the time of the inspection. Employee # 10 was due to have the communicable disease trainings no later than September 30, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD 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
On March 1, 2022, the Clinical Director created a yearly training spreadsheet and calendar that tracks counselors and support staff training requirements. The spreadsheet will be updated monthly and monitored by the Quality Improvement Manager and Clinical Director ensuring all Clear Day staff receive the required trainings within the allotted timeframe. Additionally, the Executive Director will review the training spreadsheet monthly to ensure all required staff receive 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. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency, or organization to whom the disclosure is being made.
Client # 2 was admitted on January 13, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated January 13, 2022, did not provide the name of the person, agency, or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan for correction: On 3/4/22 Clear Day's clinical director conducted a in house training on completing informed and voluntary consent for disclosure of information contained in patient records. The clinical director and compliance manager will monitor the files weekly ensuring documentation on consents are done properly.
Completion Date 3/4/2022
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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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 2 was admitted on January 13, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated January 13, 2022 did not provide the the specific information disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan for correction: On 3/4/22 Clear Day's Clinical Director conducted a in house training on completing informed and voluntary consent for disclosure of information contained in patient records. On orientation new staff members will be trained on completing informed and voluntary consent for disclosure of information contained in patient records. The Clinical Director and compliance manager will monitor the files weekly ensuring documentation on consents are done properly. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on five of six applicable client records reviewed, the facility failed to have verbal orders authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication within 3 business days from the time the order was given in client records # 2, 3, 5, 6, and 7.
Client # 2 was admitted on January 13, 2022 and was still active at the time of the inspection. A verbal order for medication was given by the physician on January 14, 2022 but was not authenticated in writing until February 16, 2022.
Client # 3 was admitted on January 17, 2022 and was still active at the time of the inspection. A verbal order for medication was given by the physician on January 20, 2022 but was not authenticated in writing by the physician.
Client # 5 was admitted on June 24, 2021and was discharged July 5, 2021. A verbal order for medication was given by the physician on July 5, 2021 but was not authenticated in writing by the physician. Verbal orders for medication given June 29 and July 2, 2021 were not authenticated in writing by the physician until July 13, 2021.
Client # 6 was admitted on November 2, 2021and was discharged December 2, 2021. Verbal orders for medication given November 10 and November 24, 2021 were not authenticated in writing by the physician until February 2, 2022.
Client # 7 was admitted on June 24, 2021and was discharged July 5, 2021. Verbal orders for medication were given by the physician on November 14, 15, and 21, 2021 but was not authenticated in writing by the physician. Verbal orders for medication given November 24 and December 4, 2021 were not authenticated in writing by the physician until February 2, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 43/29/222 the Medial Director was informed that verbal orders must be signed within 24 hours from the time of the verbal order. Medical Director was also directed to informed all Physicians at Clear Day to sign their verbal orders within 24hours. At CDT mandatory nurse's meeting the nursing staff were made aware of this policy. Nursing Director and Nurse Supervisor will oversee all Physician orders to ensure this policy is being followed. Corrective action will be implemented as needed to ensure verbal orders are being signed within the 24 hour expectation. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility unusual incident log, the facility failed to notify the department within three business days of an unusual incident involving the facility requiring the presence of police. A law enforcement agency was present at the facility on January 11, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 26, 2022, Clear Day's Clinical Director and Director of Nursing designed and implemented an incident review schedule to ensure all incidents are looked at daily by a management staff member. The schedule provides instructions on when and how incidents are to be reported into the DDAP Electronic Unusual Reporting System within the allotted timeframe. |
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 three of three applicable discharged client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within one week for a referral and thirty, sixty, and ninety days after discharge.
Client # 5 was admitted on June 24, 2021 and was discharged July 5, 2021. There was no documentation of a follow-up occurring in the client record.
Client # 6 was admitted on November 2, 2021 and discharged on December 2, 2021. There was no documentation of a 30-day follow-up in the facility follow-up log.
Client # 7 was admitted on November 9, 2021 and discharged on December 7, 2021. There was no documentation of a 30-day follow-up in the facility follow-up log.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 25, 2022, the Quality Improvement Manager and Clinical Director met and completed a strategy that will ensure a follow up contact will occur within one week of a patient's scheduled referral to an outpatient agency. The Office Manager's assistant will conduct thirty, sixty, and ninety day follow ups after a patient's discharge. Clear Day's Quality Improvement Manager and Clinical Director will monitor patient records weekly to ensure follow up calls are being conducted. |
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 seven of seven client records reviewed, the facility failed to provide documentation that work done by the client at the project is an integral part of his treatment and rehabilitation plan. Master treatment plan did not include work therapy as part of the treatment and rehabilitation plan. The facility has a sign-up sheet that allows clients to sign up to work in the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan for correction: On 3/4/22 Clear Day's clinical staff have been instructed how to incorporate work therapy as a goal on the treatment plan. Patients will be given a chore and monitored and documented daily by Clear Day's support staff and treatment team. Work therapy will be documented in the treatment plan.
Completion Date 3/4/2022
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