INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 2, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to document the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
The unusual incident reports documented six incidents that involved drugs on the premises. There was no documentation that the facility reviewed and identified the direct or indirect causes for the usual incidents.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/30/20 Clear Day's Executive Director created an Unusual Incident Policy and Procedure that indicates a prompt review and documentation of cause directly or indirectly of persons responsible. The report will document dates, times, and action steps to prevent further illegal substances or disruptions within the facility. The Executive Director or his designee is responsible for ensuring the corrective action implemented.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to document the implementation of a timely and appropriate corrective action plan for the unusual incident.
The unusual incident reports documented six incidents that involved drugs on the premises. There was no documentation that the facility implemented a timely and appropriate corrective action plan for the incidents.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/30/20 the Executive Director of Clear Day Treatment provided instructions to staff on how to complete Unusual Incident documentation on the facility's internal incident report. The report will indicate the corrective action plan within 48 hours after the unusual occurrence. Emphasis was placed on the Incident Report being timely and appropriate. A Clear Day Supervisor must review the documented incident report for timeliness and appropriate accuracy |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to document the ongoing monitoring of a corrective action plan.
The unusual incident reports documented six incidents that involved drugs on the premises. There was no documentation of the ongoing monitoring of a corrective action plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clear Day Executive Director or his designee will review every Unusual Incident within 24-48 hours after the occurrence to ensure the incident report is timely and accurate. The Clinical Supervisors will conduct and document monthly meetings for the purpose of reviewing all the unusual incidents reports to ensure corrective action protocols are being followed. |