INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted and capacity increase physical plant inspection on October 29-30, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
|
Plan of Correction
|
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
Based on a physical plant inspection conducted on October 29, 2025, the facility failed to store all garbage in covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.Black garbage bags and empty boxes were observed piled up out of the garbage receptacle and on the asphalt in front of and on both sides of the receptacle located in the parking lot.
|
Plan of Correction
We had been having difficulties with our previous trash service and were in the process of changing services. The previous service was supposed to come and clean the area allowing room for the new company to bring their dumpster. That unfortunately was not done when it was supposed, but as of Friday 10/31/2025 the old company has cleaned the area, and the new company has delivered the new dumpster. The old dumpster was removed on 11/7/2025. Going forward the director of milieu services will monitor that the dumpster is being emptied twice a week as it should. She will check the grounds daily to assure there is no garbage outside of the dumpster. If there is any problem she will call the dispatcher immediately to correct the situation. Currently the new company has been coming at their scheduled times, without a problem. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection conducted on October 29. 2025, the facility failed to ensure that heaters that are not permanently mounted or installed are not permitted.Two portable heaters were observed to be stored on the floor behind the door in the Exam Room.
|
Plan of Correction
Being behind the door staff were not aware the heaters were there. Staff was asked who they belonged to and no one knew. It has been assumed they might have been left by former staff. They have been removed from the building on 10/31/2025 and disposed of. All staff were reminded that the use of space heathers is not allowed. Going forward the supervisor of each department will monitor their staffing areas weekly to assure no one is using any heating device that is not a permanent part of the building. If any devices are found disciplinary action will be taken. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
|
Observations
Based on a review of personnel files, the facility failed to have written job descriptions for project positions inside the personnel files of two six files reviewed.Employee # 1 was hired on December 11, 2023, and was still employed at the time of this investigation.Employee # 2 was hired on December 4, 2023, and was still employed at the time of this investigation.
|
Plan of Correction
On Friday 10/31/2025 all employee charts were reviewed by supervisors to ensure a current job description was in each. Employee #1 transferred from a different position to a per diem night shift position and several attempts were made to complete the job description by her supervisor unsuccessfully. The employee has resigned as she was unable to keep her commitment with her other job. Employee #2 did have a job description completed but it was kept by her supervisor. A copy has since been added to her chart. Going forward all employees will continue to sign their job descriptions with their supervisor during their onboarding process and will immediately be filed in their personnel file by their supervisor. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
|
Observations
Based on a physical plant inspection conducted on October 29, 2025, along with staff interviews, the facility failed to follow the written policy and procedures regarding all medications used by clients.Per the facility's Medication Control policy, medication is to be stored in its original container.A syringe was observed to have been pre-filled and stored inside a refrigerator for medication. It was reported by those interviewed that the substance in the syringe was Ativan.
|
Plan of Correction
A meeting was held on 10/31/2025 with the nursing supervisor, medical director, and executive director to discuss the best practice. When a client is seizing it is time sensitive, and we were trying to find a way to be able to medicate as quickly as possible. It was decided that as of 11/05/2025 we will begin to utilize a new medication that does not need to be refrigerated so it will be easier to access when a client is seizing. The medication has been ordered, and the medical director has been working with the nursing supervisor to create a policy that will be distributed to all nursing staff on 11/04/2025 so there is time to address any questions. Going forward this will be the protocol used for any patient who is seizing. It will be supervised by the nursing supervisor. |