INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on February 19 -21 and February 27 & 28, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Clear Day of Westmoreland was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records, the facility failed to document that all counselors met the qualifications required for the position.
Staff #1 was hired as a behavioral health technician on February 10, 2025 and promoted to counselor on February 17, 2025. Staff #1 reported on their employment application that they held a bachelor ' s degree. Upon reviewing staff #1 ' s transcripts, there was no documentation the staff graduated, so the inspectors contacted the University that issued the transcripts. It was confirmed with the University that staff #1 did not graduate, but withdrew. Staff #1 does not meet the educational requirements for the position of counselor.
This was discussed with staff during the compplaint investigation.
|
Plan of Correction
The staff in question was let go on 3/1/25. Management staff (including any and all hiring managers, supervisors, directors) were reeducated on the importance of verifying educational information prior to offering a position per our company's policies and procedures. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair.
A physical plant inspection was conducted on February 19, 2025.
Room 13 - dryer sheets stuffed in the vent and a blanket hung in from on the window.
Room 9 - stained mattress cover on an unused bed.
Male lounge - broken table with stuff stored on the table.
Room 8 - stained mattress cover on an unused bed.
Room in the women section had a piece of paper hanging from the vent with tape as it appears it may be used to block the vent.
Room 23 - ceiling leaking in an unused bedroom. Trashcan used to catch the water.
Women Lounge room - couch worn and torn.
Unused counselor's office had a stained and worn chair that was used by the Program Representative Supervisor.
Hallway heading towards the kitchen had a worn, indent and cracked tile that is a possible tripped hazard.
The fence located in the back that is used by the clients was missing sections of the fence.
One chair located by detox room 13 was worn and torn.
The couch located in the detox women's lounge was worn and taped.
This was discussed with staff during the complaint investigation.
|
Plan of Correction
Dryer sheets removed as was the blanket. Staff were reeducated regarding proper inspection and cleanliness of facility. We disposed of all of the stained mattress covers and replaced them with new ones. We removed the table from the men's lounge as it was not repairable. Paper was removed from vent; patients were informed to not cover vents. Room 23: fixed and is able to have patients in it. Replaced couches in the women's lounge on both detox and rehab side. Regarding hallway tile and fence, our landlord has received bids and is planning to repair soon. Chair was removed from detox. Treatment techs will monitor daily the patients' rooms to ensure cleanliness as well as compliance with having nothing in the vents. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
|
Observations
Based on a physical plant inspection, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
A physical plant inspection was conducted on February 19, 2025. At the time of the inspection, the showers in both the male and female showers were found to not have slip-resistant surfaces or mats.
This was discussed with staff during the complaint investigation.
|
Plan of Correction
We now have slip resistant mats in each individual shower. We also installed anti-skid strips outside of showers. Executive Director and DON will monitor via monthly walk throughs. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
|
Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor.
A physical plant inspection was conducted on February 19, 2025. At the time of the inspection, two boxes of food items were found to be stored on the floor in the kitchen area.
This was discussed with staff during the compplaint investigation.
|
Plan of Correction
We reeducated dietary staff regarding food storage. All food is now stored on shelving off the floor. Treatment tech supervisor will monitor this weekly. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
|
Observations
Based on a review of client records, medication records and staff & client interviews, the facility failed to document a written or verbal physician order for medication provided.
Client #2 was admitted on January 14, 2025 and was active at the time of the investigation. Client #2 was prescribed Suboxone 8/2mg to be taken twice daily. The rehabilitation facility did not have this medication available on January 31, February 17 and February 20, 2025. It was documented that the client received Subutex from the stock medication supply in the detoxification facility on those dates. There was no written or verbal physician order documented ordering the Subutex for the dates it was provided.
This was discussed with staff during the compplaint investigation.
|
Plan of Correction
The facility's medication administration policy has been revised, to prohibit substitution of prescribed medication without documented verbal or written physician orders the revised policy was implemented 4/1/2025.
In the event a prescribed medication is unavailable, the Nursing staff will notify the provider for a substitution or new order.
All Nursing staff, received in-service training on revised policy prior to the effective date.
To further prevent medication issues, the facility hired a dedicated nurse for Rehab side effective 3/11/2025 that will be assisting in med refills communicating with physician, providing an added layer of oversight. DON will audit once per month for compliance. |
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.
|
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 to the rehabilitation level of care on January 17, 2025 and was active in treatment at the time of the investigation.
Client #1 was prescribed buprenorphine 8/2 mg 2x daily, at 8:00 AM and 4:00 PM, on January 17, 2025. On February 12, 2025, client #1 received their 8:00 AM dose at 2:28 PM and their 4:00 PM dose at 8:27 PM.
On January 20 and February 10, 2025, client #1's buprenorphine medication was documented as "medication not available".
On February 11, 2025, it was documented that client #1's buprenophine was unavailable, so the client was provided Subutex in the detox program.
Client #1 was prescribed 25 mg of Lamotrigine to be taken daily. This medication was documented as unavailable on January 22, 2025.
Client #1 was prescribed 50 mg of Sertraline to be taken daily. This medication was documented as unavailable on January 22, 2025.
Client #1 was prescribed 50 mg of Seroquel to be taken daily. This medication was documented as unavailable on January 20, 2025.
Client #2 was admitted to the rehabilitation level of care on January 14, 2025 and was active at the time of the investigation.
Client #2 was prescribed 600mg of Trazodone on January 14, 2025. Client #2 did not receive this medication as prescribed on January 17, 22, 24 and February 2, and 19, 2025. There was no reason documented for this missed medication.
Client #2 was prescribed 20mg of Fluoxetine HCI on January 14, 2025, to be taken once per day. Client #2 did not receive this medication as prescribed on February 2, 2025. There was no reason documented for this missed medication. Client #2 did not receive this medication as prescried due to the medication being unavailable on January 30, 2025.
Client #2 was prescribed 8/2mg of Suboxone on January 14, 2025, to be taken twice per day. Client #2 did not receive this medication as prescribed on February 2, 2025. There was no reason documented for this missed medication. Client #2 did not receive this medication as prescibed due to the medication being unavailable on January 30, February 14 & 15, 2025.
Client #2 was prescribed 600 mg of Gabapentin on January 14, 2025, to be taken 4 times per day. Client #2 did not receive this medication as prescribed on January 30, 2025. The reason documented was a "long med line".
Client #3 was admitted to the rehabiliation level of care on January 7, 2025 and was active at the time of the investigation.
Client #3 was prescribed 40mg of Atorvastatin, to be taken once per day, on January 1, 2025, while in the detoxification level of care. Client #3 did not receive this medication as prescribed on January 4, 2025. There was no reason documented for this missed medication.
Client #3 was prescribed 5mg of Glipizide, to be taken once per day, on January 2, 2025, while in the detoxification level of care. Client #3 did not receive this medication as prescribed on January 4, 2025. There was no reason documented for this missed medication.
Client #3 was prescribed 100/25 mg of Losartan/HCTZ, to be taken once per day, on January 2, 2025, while in the detoxification level of care. Client #3 did not receive this medication as prescribed on January 4, 2025. There was no reason documented for this missed medication.
Client #3 was prescribed 15 mg of Remeron, to be taken once per day, on January 1, 2025, while in the detoxification level of care. Client #3 did not receive this medication as prescribed on January 4, 2025. There was no reason documented for this missed medication.
Client #3 was prescribed 75 mg of Remeron, to be taken once per day, on January 2, 2025, while in the detoxification level of care. Client #3 did not receive this medication as prescribed on January 4, 2025. There was no reason documented for this missed medication.
Client #4 was admitted to the rehabilitation level of care on January 8, 2025 and discharged on February 19, 2025.
Client #4 was prescribed 15mg of Buspirone, to be taken once per day, on January 6, 2025, while in the detoxification level of care. Client #4 did not receive this medication as prescribed on January 13 and February 3, 2025. There was no reason documented for this missed medication.
Client #4 was prescribed 1000mg of Keppra, to be taken twice per day, on January 4, 2025, while in the detoxification level of care. Client #4 did not receive this medication as prescribed on January 13, 2025. There was no reason documented for this missed medication. Client #4 did not receive this medication as prescribed due to the medication being unavailable on January 9, 2025.
Client #4 was prescribed 300mg of Oxcarbazepine, to be taken once per day for 3 days then, twice per day, on January 6, 2025, while in the detoxification level of care. Client #4 did not receive this medication as prescribed on January 9, February 8 and 11, 2025. The medication was listed as unavailable.
Client #4 was prescribed 15 mg of Buspirone, to be taken three times a day, on January 6, 2025, while in the detoxification level of care. Client #4 did note receive this medication as prescribed on February 17 & 18, 2025. The medication was listed as unavailable.
Client #4 was prescribed 300 mg of Gabapentin, to be taken three times a day, on February 13, 2025. Client #4 did not receive this medication as prescribed on February 14, 2025. This medication was listed as unavailable.
Client #5 was admitted to the rehabilitation level of care on December 31, 2024 and discharged on January 31, 2025.
Client #5 was prescribed 5mg of Oxybutynin, to be taken twice per day, on December 31, 2024. Client #5 did not receive this medication as prescribed on January 13 & 20, 2025. There was no reason documented for this missed medication.
Client #5 was prescribed 40mg of Protonix DR, to be taken once per day, on December 31, 2024. Client #5 did not receive this medication as prescribed on January 20, 2025. There was no reason documented for this missed medication.
Client #5 was prescribed 50mg of Topamax, to be taken once per day, on December 31, 2024. Client #5 did not receive this medication as prescribed on January 20, 2025. There was no reason documented for this missed medication. Client #5 did not receive this medication as prescribed due to the medication being unavailable on January 31, 2025.
Client #5 was prescribed 333mg of Acamprosate Calcium DR, to be taken three times per day, on December 31, 2024. Client #5 did not receive this medication as prescribed on January 13, 20, and 22, 2025. There was no reason documented for this missed medication.
Client #5 was prescribed 600mg of Gabapentin, to be taken three times per day, on December 31, 2024. Client #5 did not receive this medication as prescribed on January 13 and 20, 2025. There was no reason documented for this missed medication. Client #5 did not receive this medication as prescribed due to the medication being unavailable on January 31, 2025.
Client #5 was prescribed 15mg of Aripiprazole, to be taken once per day, on December 31, 2024. Client #5 did not receive this medication as prescribed on January 20, 2025. There was no reason documented for this missed medication. Client #5 did not receive this medication as prescribed due to the medication being unavailable on January 8, 2025.
Client #5 was prescribed 2mg of Ozempic, to be taken once weekly, on December 31, 2024. Client #5 did not receive this medication as prescribed on January 28, 2025. This medication was documented as being unavailable.
Client #6 was admitted to the rehabilitation level of care on December 11, 2024 and discharged on January 8, 2025.
Client #6 was prescribed 4mg of Tamsulosin, to be taken once per day, on December 6, 2024. Client #5 did not receive this medication as prescribed on December 27, 2024. There was no reason documented for this missed medication.
Client #6 was prescribed 750mg of Levetiracetam, to be taken twice per day, on December 5, 2024. Client #6 did not receive this medication as prescribed on December 27 & 7, 2024. There was no reason documented for this missed medication.
Client #6 was prescribed 25mg of Metoprolol, to be taken twice per day, on December 5, 2024. Client #6 did not receive this medication as prescribed on December 7, 25 and 27, 2024. There was no reason documented for this missed medication. Client #6 did not receive this medication as prescribed due to the medication being unavailable on December 28, 2024 and January 3 & 4, 2025.
Client #6 was prescribed 1% topical Terbinafine, to be applied twice per day, on December 12, 2024. Client #6 did not receive this medication as prescribed on December 27, 2024. There was no reason documented for this missed medication. Client #6 did not receive this medication as prescribed due to the medication being unavailable on December 28, 2024.
Client #6 was prescribed 100mg of Sertraline, to be taken once per day, on December 5, 2024, while in detoxification. Client #6 did not receive this medication as prescribed on December 7 & 25, 2024. There was no reason documented for this missed medication. Client #6 did not receive this medication as prescribed due to the medication being unavailable on December 28, 2024 and January 3-5, 2025.
Client #6 was prescribed 40mg of Atorvastatin, to be taken once per day, on December 5, 2024, while in detoxification. Client #6 did not receive this medication as prescribed due to the medication being unavailable on December 28, 2024 and January 3, 2025.
Client #7 was admitted to the rehabilitation level of care on January 28, 2025 and discharged on February 25, 2025.
Client #7 was prescribed 8/2mg of Suboxone, to be taken twice per day, on January 28, 2025. Client #7 did not receive this medication as prescribed due to the medication being unavailable on February 10, 11, 12, 15 and 16, 2025.
Client #8 was admitted to the rehabilitation level of care on January 1, 2025 and discharged on January 24, 2025.
Client #8 was prescribed 250 mg of Azithromycin, to be taken once per day, on January 5, 2025. Client #8 did not receive this medication as prescribed due to the medication being unavailable on January 6, 2025.
Client #8 was prescribed 25mg of Topiramate, to be taken once per day, on January 6, 2025. Client #8 did not receive this medication as prescribed due to the medication being unavailable on January 7 & 20, 2025.
Client #8 was prescribed 20mg of Citalopram, to be taken once per day, on January 6, 2025. Client #8 did not receive this medication as prescribed due to the medication being unavailable on January 7, 12, 16 and 20, 2025.
Client #8 was prescribed 25mg of Topamax, to be taken twice per day, on December 31, 2024, while the client was in detoxification. Client #8 did not receive this medication as prescribed due to the medication being unavailable on January 5, 6, 7, and 24, 2025.
Client #8 was prescribed 10mg of Prednisone, to be taken twice per day, on January 5, 2025. Client #8 did not receive this medication as prescribed due to the medication being unavailable on January 6, 2025.
Client #8 was prescribed 20mg of Celexa, to be taken once per day, on December 31, 2024, while in detoxification. Client #8 did not receive this medication as prescribed due to the medication being unavailable on January 5, 6, 7, 12 and 17, 2025.
|
Plan of Correction
Staff were educated on current procedures for medication handling and documentation and also educated on the transitioning from EMAR to paper MAR prior implementation on 4/1/2025 on this date the rehab transitioned from electronic EMAR to paper EMAR to improve accuracy and compliance with documentation requirements that are indicated on each paper MAR, Only licensed staff and trained staff will be permitted access to the medication and medication room. To strengthen our Rehab medication oversight a full time nurse was hired 3/11/25 to ensure medications are properly logged and administered per state regulations. DON will monitor monthly for compliance. |
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.
|
Observations
Based on a review of incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving physical assault, sexual assault and/or events at the facility requiring the presence of police or an ambulance.
Alleged sexual assaults were documented to have occurred on November 1, 2024 and January 11, 2025. There was no documentation that either of these events were reported to the Department.
Alleged physical assaults were documented to have occurred on January 8 & 29, February 5, 9 and 12, 2025. There was no documentation that any of these events were reported to the Department.
The police were documented to have been onsite on January 8,12, 23 and February 1, 2025. There was no documentation that any of these events were reported to the Department.
An ambulance was documented to have been onsite on January 8 and February 7, 2025. There was no documentation that either of these events were reported to the Department.
This was discussed with staff during the complaint investigation.
|
Plan of Correction
New Executive Director was hired 3/3/25 and was educated on the unusual incident reporting protocols. Executive Director has already utilized the unusual incident form when incidents occurred. They were reported the day they happened. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on staff interviews and a review of client records, the facility failed to document work done at the the facility as an integral part of their treatment and rehabilitation plan.
It was reported by staff that all clients are assigned work therapy tasks to complete as part of their treatment. None of the client records reviewed included work therapy as part of their treatment plan.
This was discussed with staff during the compplaint investigation.
|
Plan of Correction
We have all new counselors since this inspection. They have been educated on treatment planning and specifically incorporating work therapy into the plan as well, i.e. if a patient is assigned a chore, and they volunteer to do this. Executive Director will review treatment plans weekly. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
709.17(c)(4)(i-ii) -
Based on a review of administrative information, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for medication administration activities were submitted and approved by the Department for the September 30, 2024 complaint investigation and the November 24, 2024 follow up inspection. Medication administration was again found to be a deficiency in the February 19-21 & 27-28, 2025 complaint investigation.
|
Plan of Correction
Staff re-educated on medication administration procedures, and proper documentation, transitioned from EMAR to paper MAR on 4/1/2025, on the rehab side to reduce errors and improve compliance, weekly audits by DON or approved staff will be conducted to ensure proper charting is being done. Also a full time nurse was hired 3/11/2025, specifically the Rehab side to strengthen medical over site and improve documentation compliance. DON will monitor monthly for compliance. |
709.17(a)(4) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
|
Observations
Based on a review of client records, physical plant inspection, policy and procedures manual, staff & client interviews and unusual incidents, it was found that gross incompetence, negligence and/or misconduct was present at the facility.
Multiple complaints have been filed with the Department regarding clients not receiving
their medications as prescribed. Onsite inspections/investigations were conducted on March 12, June 28, September 30, November 22, 2024 and February 28, 2025. The facility was found to be non-compliant with medication administration in each of these surveys due to clients not recieving their medications as prescribed. Plans of correction were required and submitted, yet client medication administration continues to be an area of concern.
In addition, during the complaint investigation on February 19-21, 2025, there were multiple instances involving client medications where medication was either missing or client obtaining other clients medication. The following incidents were documented without subsequent investigation and follow through:
July 10, 2024 - Client was discharged on May 27, 2024 and the facility received the client's Wellbutrin 150mg tabs (quantity of 60). Prior to the client's discharging, staff told the client that they would call him and then he could come back to pick up his medication on June 6, 2024. The facility had the client's medication locked up in the med room. Staff said on July 10, 2024, they went to destroy the medication since it has been over 30 days. Both medication cards, containing 30 tablets each, were missing. The only thing remaining was the medication discharge list. There was no documentation as to what happened to the patient's medication.
January 11, 2025 - (2 incident reports) A husband (client) passed a note to his wife (also a client) and when discovered, the note had the husband's suboxone strip in the note.
February 18, 2025 - One client was getting other clients suboxone and tested positive for buprenorphine
|
Plan of Correction
All nursing staff and med techs, and medical assistants were re-educated and trained on proper medication administration, documentation, storage, and procedure for discharge of medication,and destruction using appropriate forms,prior to 4/1/2025. A full time nurse was hired 3/11/2025 to help ensure accuracy in medication ordering, proper documentation of patient discharges, returns or destruction of medications, on 4/1/2025 the rehab transitioned to paper MAR administration to improve clarity and consistency, and accuracy, weekly audits are performed by DON or approved medical staff. DON will perform weekly audits.
|