INITIAL COMMENTS
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This report is a result of an off-site unusual incident investigation conducted on June 24, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of administrative documentation, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a physical or sexual assault by staff or a client.
It was learned that a staff person was rumored to have been in a relationship with a client and that staff person was terminated from employment on March 12, 2025. The facility did not submit a written unusual incident report to the Department within the regulatory timeframe.
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Plan of Correction
Executive Director will submit incident report regarding this incident by the end of the business day (6/30/25).
Responsible party: Moving forward, Executive Director will ensure that any unusual incidents will be submitted within 3 days. Director of Nursing will monitor monthly to ensure compliance. |