INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2024 and January 23, 2024 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of staff records, the facility failed to ensure that the Facility Director met the qualifications for the position in one of one record.Staff #2 was promoted to the position of Facility Director on December 12, 2023. At the time of the inspection, Staff #2 held a qualifying master ' s degree, but did not possess two years of experience in a human service agency which includes supervision of others, direct service, and program planning. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #2 will have 2 years of supervision experience on May 1, 2024. She will continue to receive bi-weekly supervision from the Project Director until supervision experience has been met. Clear Day will prescreen all potential candidates, assuring the candidate has all the required training and experience to fill the position. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of facility records, the facility failed to ensure that the project director prepared, annually updated and signed a written manual delineating project policies and procedures. The last signed update to the written manual was dated January 1, 2023. No update was documented for the year of 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Project Director have updated Clear Day's written manual outlining project policies and procedures. The Facility Director and Project Director will schedule meetings with relevant stakeholders to review and update existing policies and procedures as needed. Going forward, the Project Director will be responsible for annually updating and signing the written manual to ensure compliance with regulatory requirements. |
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 facility failed to ensure a copy of client consent was offered to the client in two of seven records. Client #2 was admitted to the inpatient level of care on December 19, 2023 and was active at the time of review. Client #2 record included a signed release of information dated January 12, 2024. The release of information form contained checkboxes to indicate if a copy of the release was offered to the client. No boxes were checked to document that a copy of the release of information was offered. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clear Day staff have undergone retraining focused on ensuring the thoroughness of
consents, including indicating whether a copy of the release was offered. The Facility
Director and Clinical Supervisor will continue weekly chart reviews to ensure ongoing
compliance. |
709.54(a)(1) LICENSURE Purchasing food/equipment
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(1) Purchasing of food and equipment.
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Observations
Based on a review of facility policy and procedure, as well as observations of the physical plant and information obtained from facility staff, the facility failed to ensure it followed its policy and procedures for the purchasing of food and equipment. Facility policy and procedure states that " Clear Day Treatment does not purchase food or equipment " . During a tour of the physical plant, it was observed that the facility was in possession of refrigerators and heating boxes.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clear Day has updated its project management services policy and procedures to reflect current processes regarding receiving/storing/preserving food and food equipment. All staff have been trained on the updated policy and procedures. |
709.54(a)(2) LICENSURE Receiving/storing/preserving
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a review of facility policy and procedure, as well as observations of the physical plant and information obtained from facility staff, the facility failed to ensure it followed its policy and procedures for receiving, storing, and preserving food stuff.Facility policy and procedure states that " Clear Day Treatment does not store or preserve food stuff. " During a tour of the physical plant, it was observed that the facility was storing food in refrigerators for clients, as well as boxes of snacks.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clear Day has updated its project management services policy and procedures to reflect current processes regarding receiving/storing/preserving food. All staff have been trained on the updated policy and procedures. |
709.54(a)(3) LICENSURE Proper preparation of food
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(3) Proper preparation of food.
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Observations
Based on a review of facility policy and procedure, as well as observations of the physical plant and information obtained from facility staff, the facility failed to ensure it followed its policy and procedures for proper preparation of food.Facility policy and procedure states that " CDT does not prepare food on site " . During a tour of the physical plant, it was observed that the facility uses heating boxes to prepare pre-cooked meals for clients. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clear Day has updated its project management services policy and procedures to reflect current processes regarding food preparation. All staff have been trained on the updated policy and procedures. |
709.54(a)(4) LICENSURE Safety/sanitation
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(4) Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
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Observations
Based on a review of facility policy and procedure, as well as observations of the physical plant and information obtained from facility staff, the facility failed to ensure it followed its policy and procedures for safety and sanitation, including preparation, handling and storage of foods, the care and cleaning of dishes, utensils and work area.Facility policy and procedure states that " CDT does not prepare, handle, or store food on the premises. CDT does not keep dishes or utensils on site. During a tour of the physical plant, it was observed that the facility was preparing and storing food, as well as using counters as work areas in the preparation of food. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clear Day has updated its project management services policy and procedures to reflect current processes regarding safety and sanitation. All staff have been trained on the updated policy and procedures. |