INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CleanSlate Medical Group of Pennsylvania, LLC 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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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to inspect their own records, that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client, and the reasons for removing sections shall be documented in the record. Client # 1 was admitted on November 25, 2022 and was still active at the time of the inspection.Client # 2 was admitted on March 24, 2023 and was still active at the time of the inspection.Client # 3 was admitted on December 20, 2022 and was still active at the time of the inspection.Client # 4 was admitted on November 15, 2022 and was still active at the time of the inspection.Client # 5 was admitted on January 19, 2023 and was discharged May 15, 2023.Client # 6 was admitted on November 30, 2022 and was discharged March 13, 2023.Client # 7 was admitted on January 19, 2023 and was discharged February 20, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will review its Policies & Procedures for Patient education & training to ensure documented written Patient acknowledgement is available to verify that Patients have been notified of their rights including the right to inspect their own records & that the Project, Facility or Clinical Director may temporarily remove portions of the records prior to the inspection by the Patient if the Director determines that the information may be detrimental if presented to the Patient. CleanSlate will provide Staff with additional training & education reviewing necessary protocols & documentation to verify Patients have been notified of their rights. This documentation will be obtained via an Acknowledgement of Receipt Form signed by the Patient available for review & verification within the Patient's record. CleanSlate will ensure reasons for removing any sections are documented in the Patient's record. Compliance with implementing this new Acknowledgement of Receipt Form will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to appeal a decision limiting access to their records to the director. Client # 1 was admitted on November 25, 2022 and was still active at the time of the inspection.Client # 2 was admitted on March 24, 2023 and was still active at the time of the inspection.Client # 3 was admitted on December 20, 2022 and was still active at the time of the inspection.Client # 4 was admitted on November 15, 2022 and was still active at the time of the inspection.Client # 5 was admitted on January 19, 2023 and was discharged May 15, 2023.Client # 6 was admitted on November 30, 2022 and was discharged March 13, 2023.Client # 7 was admitted on January 19, 2023 and was discharged February 20, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will review its Policies & Procedures for Patient education & training to ensure documented written Patient acknowledgement is available to verify that Patients have been notified of their rights including the right to appeal to the Director a decision limiting access to their records. CleanSlate will provide Staff with additional training & education reviewing necessary protocols & documentation to verify Patients have been notified of their rights. This documentation will be obtained via an Acknowledgement of Receipt Form signed by the Patient available for review & verification within the Patient's record. Compliance with implementing this new Acknowledgement of Receipt Form will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. Client # 1 was admitted on November 25, 2022 and was still active at the time of the inspection.Client # 2 was admitted on March 24, 2023 and was still active at the time of the inspection.Client # 3 was admitted on December 20, 2022 and was still active at the time of the inspection.Client # 4 was admitted on November 15, 2022 and was still active at the time of the inspection.Client # 5 was admitted on January 19, 2023 and was discharged May 15, 2023.Client # 6 was admitted on November 30, 2022 and was discharged March 13, 2023.Client # 7 was admitted on January 19, 2023 and was discharged February 20, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will review its Policies & Procedures for Patient education & training to ensure documented written Patient acknowledgement is available to verify that Patients have been notified of their rights including the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their own record. CleanSlate will provide Staff with additional training & education reviewing necessary protocols & documentation to verify Patients have been notified of their rights. This documentation will be obtained via an Acknowledgement of Receipt Form signed by the Patient available for review & verification within the Patient's record. Compliance with implementing this new Acknowledgement of Receipt Form will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on seven of seven client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to submit rebuttal data or memoranda to their own records.Client # 1 was admitted on November 25, 2022 and was still active at the time of the inspection.Client # 2 was admitted on March 24, 2023 and was still active at the time of the inspection.Client # 3 was admitted on December 20, 2022 and was still active at the time of the inspection.Client # 4 was admitted on November 15, 2022 and was still active at the time of the inspection.Client # 5 was admitted on January 19, 2023 and was discharged May 15, 2023.Client # 6 was admitted on November 30, 2022 and was discharged March 13, 2023.Client # 7 was admitted on January 19, 2023 and was discharged February 20, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will review its Policies & Procedures for Patient education & training to ensure documented written Patient acknowledgement is available to verify that Patients have been notified of their rights including the right to submit rebuttal data or memoranda to their own record. CleanSlate will provide Staff with additional training & education reviewing necessary protocols & documentation to verify Patients have been notified of their rights. This documentation will be obtained via an Acknowledgement of Receipt Form signed by the Patient available for review & verification within the Patient's record. Compliance with implementing this new Acknowledgement of Receipt Form will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on six of six applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 1, 2, 3, 4, 5, and 6.Client # 1 was admitted on November 25, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 23, 2023. A treatment and rehabilitation plan update was due no later than April 23, 2023. A treatment and rehabilitation plan update did not occur until May 15, 2023.Client # 2 was admitted on December 7, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 14, 2022. A treatment and rehabilitation plan update was due no later than February 14, 2023. A treatment and rehabilitation plan update did not occur until March 24, 2023.Client # 3 was admitted on December 20, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 10, 2023. A treatment and rehabilitation plan update was due no later than March 10, 2023. A treatment and rehabilitation plan update did not occur until April 6, 2023.Client # 4 was admitted on November 15, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on November 15, 2022. A treatment and rehabilitation plan update was due no later than January 15, 2023. A treatment and rehabilitation plan update did not occur until March 15, 2023. A treatment and rehabilitation plan was due no later than May 15, 2023. There was no documentation of the treatment plan in the client record.Client # 5 was admitted on January 19, 2023 and was discharged May 15, 2023. A treatment and rehabilitation plan was developed on February 13, 2023. A treatment and rehabilitation plan update was due no later than April 13, 2023. There was no documentation of the treatment plan in the client record.Client # 6 was admitted on November 30, 2022 and was discharged March 13, 2023. A treatment and rehabilitation plan was developed on December 7, 2022. A treatment and rehabilitation plan update was due no later than February 7, 2023. There was no documentation of the treatment plan in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will review its Policies & Procedures for Patient Treatment Plans to ensure documented reviews & updates of Treatment Plans are completed at least every sixty-days. CleanSlate will provide Staff with additional training & education reviewing necessary protocols for Patient Treatment Plans to be reviewed & updated timely including documented information that the Treatment Plan has been reviewed & updated by a Provider within the Patient's record. Compliance with implementing this requirement for Treatment Plan review & update frequency will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. This will additionally be supported by Clinical Leadership during supervisory reviews of Patient records conducted biannually. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 two of six applicable client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 4 and 5. Client # 4 was admitted on November 15, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on November 15, 2022 indicating an individual session weekly. A review of progress notes and record of service indicated the last individual session occurred on April 4, 2023.Client # 5 was admitted on January 19, 2023 and was discharged May 15, 2023. A treatment and rehabilitation plan was developed on February 13, 2023 indicating an individual session weekly. A review of progress notes and record of service indicated the last individual session occurred on May 1, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will provide Staff with additional training & education reviewing necessary protocols for Patient Treatment Plans to be updated to reflect that the Patient is provided with Counseling services in accordance with their current Treatment Plan including documented information that the Treatment Plan has been completed by a Provider within the Patient's record. Compliance with implementing this requirement for Counseling services to be provided in accordance with the Patient's current Treatment Plan will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. This will additionally be supported by Clinical Leadership during supervisory reviews of Patient records conducted biannually. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary is completed at the time a patient becomes discharged by a provider. Client # 5 was admitted on January 19, 2023 and was discharged May 15, 2023. The discharge summary was due to be completed no later than May 15, 2023; however, the discharge summary was not completed.Client # 6 was admitted on November 30, 2022 and was discharged March 13, 2023. The discharge summary was due to be completed no later than March 13, 2023; however, the discharge summary was not completed.Client # 7 was admitted on January 19, 2023 and was discharged February 20, 2023. The discharge summary was due to be completed no later than February 20, 2023; however, the discharge summary was not completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will provide Staff with additional training & education reviewing necessary protocols for Patient Discharge summaries to be completed at the time a Patient becomes discharged in accordance with associated Policies & Procedures including documented information that the Discharge summary has been completed by a Provider within the Patient's record. Compliance with this requirement for ensuring Discharge summaries are completed by a Provider at the time a Patient becomes discharged will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 30 days after discharge.Client # 6 was admitted on November 30, 2022 and was discharged March 13, 2023. There was no follow-up information available in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will provide Staff with additional training & education reviewing necessary protocols for Patient follow-up to occur within thirty-days after Discharge in accordance with associated Policies & Procedures including documented information that follow-up has been completed within the Patient's record. Compliance with this requirement for ensuring documented follow-up is completed with a Patient within thirty-days post-Discharge will be accomplished through ongoing monitoring activities conducted by the Center Manager responsible for Operations of the facility & audited by the Compliance Department. Chart reviews are to be conducted on a quarterly-basis on a representative sample of Patients. |