INITIAL COMMENTS
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This report is a result of on-site and telephone complaint investigations conducted on August 21-23, 2024 and September 30, 2024 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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709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on a review of client records, the facility failed to make all client records readily accessible for a minimum of 4 years following the discharge of a client.DDAP staff requested information from client record #1 as part of a complaint investigation. Documentation from the client record #1 was sent via email on September 17, 2024 and was reviewed on September 30, 2024. All of the requested information was not provided as it was unable to be retrieved. It was reported that the facility had changed their electronic client recordkeeping system and parts of the record were unable to be retrieved.
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Plan of Correction
Clear Day switched EHR's in March of 2024, and many of the files could not be transferred into the new system. Once this was discovered, access to the old EHR was not available anymore to be able to fix the issue. Clear Day will continue to use the current EHR system. If there is ever a need to switch again, the facility director will ensure charts will be transferred over before losing access to the current EHR. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records, the facility failed to maintain a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.DDAP staff requested information from client record #1 as part of a complaint investigation. Documentation from the client record #1 was sent via email on September 17, 2024 and was reviewed on September 30, 2024. All of the requested information was not provided as it was unable to be retrieved. It was reported that the facility had changed their electronic client recordkeeping system and parts of the record were unable to be retrieved.
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Plan of Correction
Clear Day switched EHR's in March of 2024, and many of the files could not be transferred into the new system. Once this was discovered, access to the old EHR was not available anymore to be able to fix the issue. Clear Day will continue to use the current EHR system. If there is ever a need to switch again, the facility director will ensure charts will be transferred over before losing access to the current EHR. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician.Client #1 was admitted on June 29, 2024, and discharged on August 7, 2024. The client was prescribed a topical medication on June 29, 2024 that was instructed to be applied topically twice per day. The client did not receive the medication as prescribed on July 1, 6 and 7, 2024, as the medication was documented as being unavailable.A second topical medication was prescribed on June 29, 2024 that was instructed to be applied topically twice per day. The client did not receive the medication as prescribed on July 6, 7, 8, 9, 14, 18, 20, 21, 23, 24, 25, 26 and 27, 2024, as the medication was documented to be unavailable. The client was documented as being unavailable on July 10, 17, 19, and 22, 2024. The medication was documented as being "missed" with no explanation on July 11, 16, 21, 28, 30, 31 and August 2, 3, 4 and 7, 2024. A third medication was prescribed on June 19, 2024 that instucted the client to take 250mg daily. The medication was not available on July 9 & 14, 2024. The client was documented as unavailable to take the medication on July 10, 2024.A fourth medication was prescribed on June 19, 2024 that instructed the client to take 75mg four times daily. The client was listed as unavailable to take the medication on July 13, 2024. The medication was documented as being "missed" on July 1, 2024, with no explanation.A fifth medication was prescribed on June 19, 2024 that instructed the client to take 400mg two times daily. The client was documented as unavailable to take the medication on July 19, 2024. The medication was documented as being "missed" on July 1 and August 2, 3, 4 & 7, 2024, with no explanation. The medication was documented as unavailable on August 7, 2024.A sixth medication was prescribed on June 19, 2024 that instructed the client to take 25mg two times daily. The medication was documented as being "missed" on August 7, 2024 with no explanation. The medication was documented as unavailable on July 20-23, 2024.A seventh medication was prescribed on June 19, 2024 that instructed the client to take .1mg once daily. The medication was documented as unavailable on July 21, 2024.An eighth medication was prescribed on July 19, 2024 that instructed the client to take 50mg two times daily for seven days. The medication was documented as unavailable on July 20-22 & 30-31, August 2, 4 & 5, 2024. It was documented that the client refused the medication on August 1, 2024; however, the comment noted stated "short staffed."A ninth medication was prescribed on June 29, 2024 that instructed the client to take 150mg daily at bedtime. The medication was documented as being unavailable on July 31 and August 3, 2024. The medication was documented as being missed with no explanation on August 2 & 4, 2024.Client #2 was admitted on July 23, 2024 and discharged on August 10, 2024.The client was prescribed a medication on July 29, 2024 that instructed the client to take 8/2mg twice per day. The medication was listed as being unavailable on August 6, 2024.A second medication was prescribed on July 29, 2024 that instruced the client to take 500mg twice per day. The medication was documented as being unavailable on August 5-9, 2024.Client #3 was admitted on July 16, 2024 and discharged on August 16, 2024.The client was prescribed a medication on July 16, 2024 that instructed the client to take 8/2mg twice per day. The medication was listed as being unavailable on July 17 and August 4-9, 2024. The medication was documented as being "missed" with no explanation on July 21 & 23 and August 6 & 7, 2024.A second medication was prescribed on July 16, 2024 that instucted the client to take 250mg daily. The medication was not available on July 9 & 14, 2024. The client was documented as unavailable to take the medication on July 10, 2024.A third medication was prescribed on July 16, 2024 that instucted the client to take 1000mg twice per day. The medication was not available on July 21, 2024.
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Plan of Correction
On 8/7/24, the Medication Control Plan was updated by the director and an external training agency. On 9/9/24, the former Director of Nursing conducted a training on the Medication Control Plan. All staff who observe a client's self-administration of medications were shown how to properly mark whether a client was unavailable, or a medication was unavailable. A note is to be entered in the medication log to clearly distinguish the reasoning for missing a medication. Only med techs and the medical assistant will be observing medication and are able to type a note in the system. The Director of Nursing will continue to complete chart audits to ensure the medication observations entries are completed correctly. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records and client interviews, the facility failed to document that counseling is provided according to the individual treatment and rehabilitation plan.Client #4 was admitted on July 12, 2024 and was active at the time of the investigation. The client's treatment plan, dated July 17, 2024, stated that individual counseling was to occur once per week. The client did not have any individual counseling documented for the week of August 4, 2024.Client #5 was admitted on July 13, 2024 and was active at the time of the investigation. The client's treatment plan, dated July 17, 2024, stated that individual counseling was to occur once per week. The client did not have any individual counseling documented for the week of August 4 and August 11, 2024.
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Plan of Correction
The facility director has hired a new counseling staff as of August 26, 2024, who has been trained to meet the counseling requirements, which consists of completing a 1-hour counseling session weekly. If a counselor is going to be off work, they should arrange for another clinical team member to meet with their client on the scheduled session day and time. The facility director will continue to audit client charts to ensure that each client receives a one-hour counseling session each week. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and client interviews, the facility failed to document that counseling is provided on a regular and scheduled basis.Client #4 was admitted on July 12, 2024 and was active at the time of the investigation. As per agency policy and the client's treatment plan, individual counseling was to occur once per week. The client did not have any individual counseling documented for the week of August 4, 2024.Client #5 was admitted on July 13, 2024 and was active at the time of the investigation. As per agency policy and the client's treatment plan, individual counseling was to occur once per week. The client did not have any individual counseling documented for the week of August 4 and August 11, 2024.
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Plan of Correction
The facility director has hired a new counseling staff as of August 26, 2024, who has been trained to meet the counseling requirements, which consists of completing a 1-hour counseling session weekly. If a counselor is going to be off work, they should arrange for another clinical team member to meet with their client on the scheduled session day and time. The facility director will continue to audit client's charts weekly to ensure that each client is being provided with counseling services on a regular basis. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to maintain a complete client record which includes the information relative to the client's involvment with the project.DDAP staff requested information from client record #1 as part of a complaint investigation. Documentation from the client record #1 was sent via email on September 17, 2024 and was reviewed on September 30, 2024. All of the requested information was not provided as it was unable to be retrieved. It was reported that the facility had changed their electronic client recordkeeping system and parts of the record were unable to be retrieved.
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Plan of Correction
Clear Day switched EHR's in March of 2024, and many of the files could not be transferred into the new system. Once this was discovered, access to the old EHR was not available anymore to be able to fix the issue. Clear Day will continue to use the current EHR system. If there is ever a need to switch again, the facility director will ensure charts will be transferred over before losing access to the current EHR. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, facility policy & procedures and client interviews, the facility failed to follow their aftercare planning policy.According to facility policy, "Aftercare planning will be considered at the time of admission and will be part of treatment planning. Relevant, clinical information is transmitted from the discharge provider (counselor) to the follow up care provider. Continuing care appointments are established prior to the patient's discharge in collaboration with the patient, continuing care coordinator and counselor."Client #4 was admitted on July 12, 2024 and was active at the time of the investigation. There was no completed aftercare plan documented in client record #4 and it was reported that client #4 had completed the program; however, there was no aftercare set up to date. It was futher reported that clients are making their own aftercare calls as there are no staff available to assist.Client #5 was admitted on July 13, 2024 and was active at the time of the investigation. There was no completed aftercare plan documented in client record #5 and it was reported that client #5 had completed the program; however, there was no aftercare set up to date. It was futher reported that clients are making their own aftercare calls as there are no staff available to assist.
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Plan of Correction
The facility director has hired a new counseling staff as of August 26, 2024, who has been trained to meet the counseling requirements, which consists of assisting their clients with setting up aftercare planning. Transition planning begins at admission and is documented throughout the treatment plan under the discharge planning section. At the time of discharge, a client should have an aftercare plan they signed off on. The facility director will continue to monitor client charts to ensure they are being set up with aftercare services throughout their treatment stay, and that the aftercare form is completed in the client chart. |