INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4, 2021 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document 25 clock hours of annual training required for counselors in one of one personnel records reviewed on March 4, 2021.
Counselor # 3 was hired July 2, 2018. Counselor # 3 only had 14 clock hours of training documented for the facility training year of July 1, 2019 through June 30, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: Clear Day's Clinical Director created a staff yearly training record for tracking staff training hours. The staff training record will run from July to June. The Clinical Director will monitor the record quarterly ensuring counselors meet the 25 hours of required trainings according to 704.11 Licensure Training Regulations. Completion on 3-11-21 |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a dated witness signature on the consent to release information form in five of six client records reviewed on March 4, 2021.
Consents for the funding entity were obtained during the intake process and did not include the dated witness signature.
Client # 1 was admitted January 8, 2021 and discharged February 10, 2021.
Client # 2 was admitted December 14, 2020 and discharged December 28, 2020.
Client # 3 was admitted January 27, 2021 and discharged February 26, 2021.
Client # 4 was admitted January 4, 2021 and discharged February 5, 2021.
Client # 6 was admitted February 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: Clear Day's Administrative Staff and Electronic Records support staff conducted a review of all Clear Day's consents correcting all release of information documents that lacked a dated witness signature line. The review and corrections were completed on 3-11-21. Clear Day's Clinical Director will conduct monthly chart reviews ensuring consent are completed correctly. Completion on 3-11-21 |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the expiration date on the consent to release information form in five of six client records reviewed on March 4, 2021.
Consents for the funding entity were obtained during the intake process and did not include the expiration date.
Client # 1 was admitted January 8, 2021 and discharged February 10, 2021.
Client # 2 was admitted December 14, 2020 and discharged December 28, 2020.
Client # 3 was admitted January 27, 2021 and discharged February 26, 2021.
Client # 4 was admitted January 4, 2021 and discharged February 5, 2021.
Client # 6 was admitted February 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: Clear Day's Administrative Staff and Electronic Records support staff conducted a review of all Clear Day's consents correcting all release of information documents that lacked the expiration date on the document. The review and corrections were completed on 3-11-21. Clear Day's Clinical Director will conduct weekly chart reviews ensuring consent are completed correctly. Completion on 3-11-21 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the client handbook and orientation documents, the facility failed to document a copy of the client consents were offered to the client in six of six records reviewed on March 4, 2021.
There was no documentation in the following records that copies of the consents to release information obtained during the intake process for the funding entity, laboratory and emergency contact were offered to the client.
Client # 1 was admitted January 8, 2021 and discharged February 10, 2021.
Client # 2 was admitted December 14, 2020 and discharged December 28, 2020.
Client # 3 was admitted January 27, 2021 and discharged February 26, 2021.
Client # 4 was admitted January 4, 2021 and discharged February 5, 2021.
Client # 5 was admitted January 4, 2021 and discharged February 26, 2021.
Client # 6 was admitted February 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: Clear Day's Administrative Staff and Electronic Records support staff conducted a review of all Clear Day's client handbook and orientation documents that lacked a check box to accept or refuse a copy of the document. The review and corrections were completed on 3-11-21. Clear Day's Clinical Director will conduct weekly chart reviews ensuring the patient handbook and orientation documents are completed correctly. Completion on 3-11-21 |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility's physician failed to document evidence of a one year history of addiction prior to the administration of Suboxone for maintenance treatment in one of three patient records reviewed on March 4, 2021.
Client # 1 was admitted January 8, 2021 and discharged February 10, 2021. The patient was administered Suboxone 8 mg/2 mg on January 11, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: Clear Day's Medical Directors have instructed all medical doctors on staff to use the suboxone pre-screen document or patient physical in the electronic record to indicate a one-year history of addiction before prescribing and administering suboxone maintenance. Clear Day's Nursing Director will monitor and review medical files to ensure Clear Day is complaint with 715.9 licensure regulation. Completion on 3-11-21 |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document an individual treatment plan that included the type and frequency of treatment and rehabilitation services in five of six client records reviewed on March 4, 2021.
Client # 1 was admitted January 8, 2021 and discharged February 10, 2021. The treatment plan was documented January 11, 2021.
Client # 2 was admitted December 14, 2020 and discharged December 28, 2020. The treatment plan was documented December 15, 2021.
Client # 3 was admitted January 27, 2021 and discharged February 26, 2021. The treatment plan was documented January 29, 2021.
Client # 5 was admitted January 4, 2021 and discharged February 26, 2021. The treatment plan was documented January 29, 2021.
Client # 6 was admitted February 7, 2021. The treatment plan was documented February 18, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: Clear Day's Clinical Director conducted a 90-minute training 3-10-21 with all the counselors reviewing treatment planning in the electronic records. The training demonstrated how to document type and frequency of services. Clear Day Clinical Director will monitor treatment plans weekly ensuring documentation is correct according to 709.52 regulations. Completion on 3-11-21 |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete client record including a discharge summary in two of five client records reviewed on March 4, 2021.
Client # 1 was admitted January 8, 2021 and discharged February 10, 2021.
Client # 2 was admitted December 14, 2020 and discharged December 28, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action: Clear Day's Clinical Director conducted a 90-minute training 3-10-21 with all the counselors reviewing treatment planning and discharge documentation in the electronic records. The training discussed the importance of the discharge process and documentation. Clear Day's Clinical Director will monitor treatment plans weekly ensuring documentation of the discharge summary is completed to be compliant with 709.53 regulations. Completion on 3-11-21 |