INITIAL COMMENTS
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This report is a result on-site complaint investigations conducted on July 8-9, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigations, 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.
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Plan of Correction
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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.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe and sanitary.
During the physical plant inspection, the following was observed:
The male restroom in the rehab unit was found to have a toilet paper dispenser broken, the shower head in the male unit was unable to be attached to the mounting, the shower head in the female restroom was broken and spouting water, the door knob was broken in the women's detox restroom, and a dining room table was found to have a hole.
These findings were reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
Increase maintenance walk throughs once per week. Also, we have ordered the appropriate fixtures to repair what is broken.
Responsible party: Executive Director and DON will share responsibility and inspect weekly. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, the facility failed to provide toilet paper at each toilet at all times.
Toilet paper was observed to be missing in the rehab male unit restroom.
These findings were reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
The stall in question was missing the toilet paper dispenser and had recently run out of toilet paper. We have contacted Cintas to install a new dispenser.
Responsible party: Treatment techs will do daily walk throughs of patient bathrooms to ensure that there is toilet paper in each stall. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor.
Three boxes of sugar were observed to be sitting on the floor.
These findings were reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
Executive Director reminded all staff via email that all boxes placed in the kitchen need to be off of the floor.
Responsible party: Kitchen staff will ensure that any and all boxes are stored in the appropriate locations daily. |
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 unusual incident reports and administrative documentation, the facility failed to document that a report was filed with DDAP within 3 business days following an event involving the presence of police, fire or ambulance personnel.
Ambulances were documented to be on facility grounds on June 20 & 26 and July 1 & 2, 2025. There was no documentation that an unusual incident report was filed with DDAP for any of these incidents.
These findings were reviewed with facility staff during the onsite complaint investigation.
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Plan of Correction
Executive Director was re-educated on the specific items that needed to be reported.
Responsible party: Executive Director and DON will ensure that all incidents are properly reported. ED and DON will communicate weekly regarding incident reports. |