INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clearvision Health and Wellness-Hazelton 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in one out of six employee records reviewed.
Employee #1 was hired on December 4, 2023 as a Project Director and was still in the position as of the date of the inspection. The individual training plan documented in the record was dated December 4, 2023. There was no documentation of an annual update in the record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Going forward all training plans will be completed and in the employee's chart before the due date. This will be monitored by both the clinical supervisor and the Executive Director. As of this date employee #1's treatment plan has been added to her chart. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from December 2023- November 2024, the facility failed to conduct a fire drill during sleeping hours at least every six months. According to the fire drill log there was one fire drill that occurred on January 27, 2024 during sleeping hours and no additional documentation that another one occurred prior to the licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward all drills will be scheduled to assure that they are being done on different shifts. As the drills are completed it will be monitored by the executive director to assure they are being done on each shift and a minimum of two will be done overnight each year. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in one out of one applicable record reviewed.
Client #10 was admitted to residential rehabilitation level of care on October 10, 2024 and discharged against facility advice on October 19, 2024.
This is a repeat citation from the December 12, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward each discharge will be reviewed by the Clinical Supervisor, if the discharge occurs after hours when the Clinical Supervisor will not be able to review within the given time the Executive Director will review to assure the call has been made. If the call has not been made the reviewing staff member will make it at that time. |
709.28(c)(3) 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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in two out of fourteen records reviewed.
Client #7 was admitted to the detox unit on January 29, 2024 and was discharged on February 6, 2024. The record contained an informed and voluntary consent to release information form for a family member dated January 29, 2024, that did not include the purpose of disclosure.
Client #13 was admitted to the residential level of care on December 2, 2024 and was still active at the time of the inspection. The record contained an informed and voluntary consent to release information form for an employment agency dated December 4, 2024, that did not include the purpose of disclosure.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff who complete releases with the clients were trained on the proper way to complete them during a staff meeting on 12/16/2024. The importance of completing each section and providing the purpose of the release was discussed. Going forward releases will be check by the clinical supervisor after completion. The clinical supervisor will notify the executive director if the releases are not being completed appropriately so further training can be scheduled. The review of releases will be done by the clinical supervisor on an ongoing basis. |