INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigations conducted on April 29 - May 2, 2025 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the facility's policy and procedures manual, the project failed develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
DDAP staff reviewed the facility's policy and procedure manual, there was no documentation of procedures that address this requirement.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated to include all required components for recruitment, hiring, and representation of population served.
Responsible party: Human Resources Manager to monitor as we hire staff.
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedures manual, the project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion.
DDAP staff reviewed the facility's policy and procedure manual. The facility's policies did not address the mechanism for collection of feedback on completed trainings. Additionally, the facility's policies did not address the annual evaluation of the overall training plan.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Each staff must complete a training feedback form within one week of their training and turn it into their department head.
Responsible party: Department heads to turn them into HR who will cross reference and check ensure compliance. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's staff development program, the facility failed to develop an assessment of staff training needs for the 2025 training year.
DDAP staff reviewed the facility's staffing documentation, there was no documentation of an assessment of staff training needs for the 2025 training year.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedures were updated to comply with 704.11; we will utilize the calendar year for our training year. We will distribute and collect the training needs form in December.
Responsible party: Executive Director will collect necessary paperwork in December of the calendar year.
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's staff development program, the project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an overall plan for addressing these needs.
DDAP staff reviewed the facility's staffing documentation. There was no documenation that the facility developed a comprehensive staff development program for the current training year, January 1, 2025 through December 31, 2025.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedures were updated to comply with 704.11; we have developed a staff development program per the regulations for this year.
Responsible party: Executive Director will review and create this annually in January.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's staff development program, the project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan.
DDAP staff reviewed the facility's staffing documentation, there was no documentation of the annual evaluation of the overall training plan for the 2025 training year.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated to include all components of 704.11. Executive Director will complete the overall training review for Clear Day staff from the previous calendar year in January of the new calendar year.
Responsible party: Executive Director will review and assess training needs from previous calendar year in January of the new calendar year. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection the facility failed to maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
It was observed, by DDAP staff, that a portion of the fence enclosing the patient's outside recreation area was missing and in need of repair.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fence was repaired on 5/9/2025.
Responsible party: Safety and Security Management does a walk through at least once per month. |
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.
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Observations
Based on a physical plant inspection the facility failed to 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.
The following was observed by DDAP staff during the course of the physical plant inspection:
12, the plastic base board was damaged and needed repair.
13, missing overhead HVAC vent cover
14, a ceiling light was non-functional
20, dryer sheets blocking HVAC vent
7, the cover of the electrical outlet was singed/burned.
9, the cover of the electrical outlet was singed/burned.
23, water damaged ceiling in need of repair
men's lounge, damaged plaster and stained chair.
female common area, broken hand sanitizer dispenser and stained chair.
recreation room, damaged hand sanitizer dispensers.
entrance of the detox, falling ceiling tiles.
detox common area, thermostat cover was missing, water damaged ceiling and couch with ripped arm.
residential hallway, off the main entrance, near the director's office, thermostat with missing cover.
the parking lot and driveway, several large potholes that need repair.
Dining area, damaged dining table, damaged plaster and broken chair rail.
Kitchen food prep area, damaged flooring
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We corrected the issues identified. We repaired: the baseboard, the HVAC vent cover, the electrical outlets, the male and female lounge issues, all of the hand sanitizers, the ceiling tiles, ceiling light, all thermostats have covers now, dining table removed, chair rail repaired, and plaster patched. Landlord is getting bids for the pothole and water damage.
Responsible party: Safety and Security Manager does monthly rounds and reports findings to COO and Executive Director. |
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.
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Observations
Based on a physical plant inspection the facility failed to 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.
DDAP staff observed that both of the dumpsters in front of the facility were open at the time of the inspection. One dumpster lids were broken and one of the lids were lying on the ground beside the dumpster. Additionally, the garbage can in the kitchen did not have a functional lid.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We made contact with our contracted waste management company who installed the new lid on 6/20/25.
Responsible party: Safety and Security will monitor during monthly rounds. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
It was observed by DDAP staff that the dinning area of the facility had a wall mounted video camera. The facility conducts group and family therapy sessions in this portion of this facility, these sessions were also observed by DDAP staff.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director submitted a request for an exception to this standard. Until then, we are turning cameras off during group times. |
705.5 (a) (2) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(2) A pillow and bedding appropriate for the temperature in the facility.
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Observations
Based on a physical plant inspection the facility failed to provide a pillow and bedding appropriate for the temperature in the facility.
DDAP staff observed the following during the physical plant inspection:
11, stains on the mattress cover.
10, stains on the mattress cover.
20, torn mattress cover.
7, stains on the mattress cover
8, stains on the mattress cover
9, stains on the mattress cover
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All mattress covers that were identified as stained or in disrepair were replaced on 5/2/25.
Responsible party: Treatment tech supervisor does weekly inspections of mattress covers. |
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.
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Observations
Based on the physical plant inspection the facility failed to 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.
DDAP staff observed that one of the men's showers did not have a slip-resistant mat.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/2/25, the Treatment Tech Supervisor placed a slip resistant mat in the men's shower. There are now slip resistant surfaces/mats in all of the showers.
Responsible party: Treatment tech supervisor does weekly rounds and inspects to ensure compliance. |
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.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. DDAP staff observed a portable heater in the office manger's workspace.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff were reeducated regarding use of space heaters. The one that was found has been removed. There are no more in the facility.
Responsible party: Safety and Security does a monthly walk through. |
705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for the evacuation of residents and staff to a safe location.
DDAP staff reviewed the facility's policy regarding emergency evacuation of residents to a safe location, this policy did not address the procedure for events that requires patients to remain onsite or shelter in place.
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Plan of Correction
Policy and procedure manual was updated to include all required components of the evacuation procedure.
Responsible party: Treatment Tech Supervisor oversees the monthly fire drills and procedures.
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705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for the evacuation and transfer of residents imparted by alcohol or other drugs.
DDAP staff reviewed the facility's policy and procedure manual, there was no documentation of a policy that addresses this requirement.
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Plan of Correction
Policy and procedure manual was updated to include all of the required components for facility evacuation.
Responsible party: Treatment Tech Supervisor monitors fire drill procedures monthly. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
DDAP staff observed that the exit from the recreation room was partially blocked and the in the kitchen it was observed that clients had their chairs blocking the exit. In addition, the back exit out of the detox was obstructed by chairs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The obstructions in the recreation room, the kitchen area, and the detox exit were remedied while our inspection was being held.
Responsible party: Treatment techs do rounds every shift and are responsible for ensuring compliance. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon staff employment in 4 of 5 personnel records.
Staff #1 was hired on March 3, 2025. There was no documentation of fire extinguisher training in staff record #1.
Staff #2 was hired on February 25, 2025. There was no documentation of fire extinguisher training in staff record #2.
Staff #3 was hired on January 31, 2025. Staff #3 did not have documentation of fire extinguisher training until February 10, 2025.
Staff #4 was hired on March 10, 2025. There was no documentation of fire extinguisher training in staff record #4.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Office Manager was reeducated on the importance of fire extinguisher training at hiring. It is now in the initial paperwork that we give new employees at hiring.
Responsible party: Office Manager will ensure compliance at each new hiring. Executive Director will check monthly for compliance. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform tasks during emergencies in 4 of 5 personnel records.
Staff #1 was hired on March 3, 2025. There was no documentation of emergency training in staff record #1.
Staff #2 was hired on February 25, 2025. There was no documentation of emergency training in staff record #2.
Staff #3 was hired on January 31, 2025. Staff #3 did not have documentation of emergency training until February 10, 2025.
Staff #4 was hired on March 10, 2025. There was no documentation of emergency training in staff record #4.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Office Manager was reeducated on the importance of emergency training at hiring. It is now in the initial paperwork that we give new employees at hiring.
Responsible party: Office Manager will ensure compliance at each new hiring. Executive Director will check monthly for compliance.
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705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers were mounted to the wall.
The fire extinguisher located in the kitchen was not secured to the wall.
This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The part that was needed to affix it to the wall was received and installed on 6/11/25.
Responsible party: Safety and security officer will inspect during monthly inspections. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of detox and residential fire drill logs from January 2024 - February 2025, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring in detox for the month of January 2025. Additionally, there was no documentation of a fire drill occurring in residential for the month of February 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Policy and procedure manual updated to include all components of 705.28 including monthly unannounced fire drills. Staff responsible are trained by the Treatment Tech Supervisor.
Responsible party: Treatment tech supervisor will review monthly fire drills to ensure compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of detox and residential fire drill logs from January 2024-February 2025, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. A review of the fire drills, by DDAP staff, revealed that the facility was not specifically documenting whether or not the fire alarm or smoke detector was operative.
This finding was discussed with facility staff during the licensing inspection.
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Plan of Correction
Policy and procedure manual updated to include all components of 705.28 including whether the fire alarm/smoke detector is operative and then is documented in the fire drill log.
Responsible party: Treatment tech supervisor to monitor during monthly fire drills.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of detox and residential fire drill logs from January 2024-February 2025, the facility failed to prepare alternate exit routes to be used during fire drills. A review of fire drills, by DDAP staff, revealed that the facility was noting " front door " for all drills from the detox and residential.
This finding was discussed with facility staff during the licensing inspection.
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Plan of Correction
Policy and procedure manual updated to include all components of 705.28 including all aspects of fire drills. The exit routes will be documented via the fire drill log and will be alternated.
Responsible party: Treatment tech supervisor will vary exit routes during monthly fire drills and document that accordingly.
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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 the policy and procedure manual, the facility failed to document that the project director updated and signed the written policy manual.
The policy manual was last reviewed and signed by the project director on January 25, 2024.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director has reviewed the current policies and procedure manual and has signed off on it.
Responsible party: Executive Director to complete every January. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients that included case consultations.
The policy and procedure manual did not include a timeframe for the completion of case consultations. It was documented that they are completed on an "as needed" basis. There were a total of fifteen client records reviewed and none included the documentation of a case consultation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated to include a scheduled time for case consults (at the same time as the treatment plan update) and also includes as needed case consults.
Responsible party: Executive Director to monitor via weekly chart audits.
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709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures that included the orientation of new employees.
The policy and procedure manual did not include the timeframe for the completion of new employee orientation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff members will receive new hire orientation packet along with a list of the trainings that are required of them specific to their job duty. The new hire orientation packet is done within the first 2 work days of hire and before employee has begun active job duty.
Responsible party: Each department head is responsible for following up with their new hire. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of policy & procedures and client records, the facility failed to document and obtain written acknowledgement by clients that a client receiving care or treatment under section 7 of the act (71 P.S. 1690.107) shall retain civil rights and liberties except as provided by statute.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual as well as the patient handbook was updated to include all components of 709.30.
Responsible party: Treatment Tech Supervisor puts together the folder with all admission paperwork on it. Will check monthly to ensure compliance.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of medication storage inspection logs, the facility failed to document medication storage inspections, at least quarterly, as per agency policy.
The medication storage inspection logs were requested for March 2024 - April 2025. There was only one medication storage inspection documented for the rehabilitation medication area that was dated April 1, 2025.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated to included medication control and inspection regulations from 709.32. Nursing staff were trained on it as well.
Responsible party: Director of Nursing will inspect monthly.
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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 an inspection of the medication carts and a review of client records, the facility failed to follow their policy for medication destruction after client discharge. The facility policy states that medications will be destroyed 30 days post discharge.
Client #16 was admitted on March 14, 2025 and discharged March 21, 2025. The medication cart inspection was conducted on April 29, 2025 and client #16's medication was still present in the cart.
Client #17 was admitted on February 18, 2025 and discharged February 21, 2025. The medication cart inspection was conducted on April 29, 2025 and client #17's medication was still present in the cart.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated to included medication control and inspection regulations from 709.32. Nursing staff were trained on it as well.
Responsible party: Director of Nursing will inspect monthly.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document a written involuntary termination notice in 2 of 2 client records.
Client #14 was admitted on April 6, 2025 and involuntarily terminated from treatment on April 15, 2025. There was no notice of involuntary termination in client record #14.
Client #15 was admitted on March 18, 2025 and involuntarily terminated from treatment on April 23, 2025. There was no notice of involuntary termination in client record #15.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated as was the patient handbook to include information on involuntary termination of treatment.
Responsible party: Counselor gives the administrative discharge documentation to the client. Reviewed monthly by Executive Director during regular chart audits.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document clients were provided the opportunity to request reconsideration of the decision to involuntary terminate their treatment in 2 of 2 client records.
Client #14 was admitted on April 6, 2025 and involuntarily terminated from treatment on April 15, 2025. There was no documentation that client #14 was provided the opportunity to request reconsideration of the decision to involuntary terminate their treatment.
Client #15 was admitted on March 18, 2025 and involuntarily terminated from treatment on April 23, 2025. There was no documentation that client #14 was provided the opportunity to request reconsideration of the decision to involuntary terminate their treatment.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated as was the patient handbook to include information on involuntary termination of treatment and how to appeal that decision.
Responsible party: Counselor gives the administrative discharge documentation to the client. Reviewed monthly by Executive Director during regular chart audits.
Responsible party: Counselor gives administrative discharge documentation to client. Reviewed monthly by Executive Director.
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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.
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Observations
Based on a review of client records and unusual incident reports, the facility failed to notify the Department within 3 business days of physical assault by staff or a client.
Client #14 was admitted on April 6, 2025 and involuntarily terminated from treatment on April 15, 2025 for physically assaulting a staff member. There was no documentation that the facility notified DDAP within 3 business days of the incident.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual was updated to include all components of 709.34 regulations.
Responsible party: Executive Director is the person responsible for submitting incident reports. All incident reports come to the Executive Director for review and notification purposes. Reviewed monthly.
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709.64(a)(1) LICENSURE Purchasing food/equipment
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(1) Purchasing of food and equipment.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the purchasing of food and equipment.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.64.
Responsible party: Kitchen staff inspects weekly. |
709.64(a)(2) LICENSURE Receiving/storing/preserving food
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(2) Receiving, storing and preserving of food stuff.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the receiving, storing and preserving of food stuff.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.64.
Responsible party: Kitchen staff inspects weekly.
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709.64(a)(3) LICENSURE Food preparation
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(3) Proper preparation of food.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the proper preparation of food.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.64 including preparation of food.
Responsible party: Kitchen staff inspects weekly.
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709.64(a)(4) LICENSURE Safety/sanitation
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(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 the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.64 including safety, sanitation, preparation, handling, storage, cleaning/care of dishes/utensils, and work area.
Responsible party: Kitchen staff inspects weekly.
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709.64(a)(5) LICENSURE Personal Hygiene
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(5) Personal hygiene for those in food preparation areas.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included personal hygiene for those in food prepartation areas.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.64 including personal hygiene for staff in food preparation areas.
Responsible party: Kitchen staff inspects weekly.
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709.64(a)(6) LICENSURE Special dietary needs
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(6) Special dietary needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included special dietary needs.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.64 including special dietary needs.
Responsible party: Admissions staff reports to nursing regarding any dietary restrictions as reported by the client at admission. Nursing then passes that along to the kitchen staff which is then posted on a white board inside the kitchen.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individualized treatment and rehabilitation plan, as per facility policy of 3 days, in 7 of 9 client records.
Client #5 was admitted on April 8, 2025 and was active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in client record #5.
Client #7 was admitted on March 26, 2025 and discharged on April 3, 2025. There was no individual treatment and rehabilitation plan documented in client record #7.
Client #8 was admitted on March 13, 2025 and discharged on March 18, 2025. There was no individual treatment and rehabilitation plan documented in client record #8.
Client #9 was admitted on March 3, 2025 and discharged on April 9, 2025. There was no individual treatment and rehabilitation plan documented in client record #9.
Client #10 was admitted on March 3, 2025 and discharged on April 2, 2025. There was no individual treatment and rehabilitation plan documented in client record #10.
Client #11 was admitted on March 13, 2025 and discharged on April 10, 2025. There was no individual treatment and rehabilitation plan documented in client record #11.
Client #12 was admitted on February 26, 2025 and discharged on March 21, 2025. There was no individual treatment and rehabilitation plan documented in client record #9.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director retrained clinical staff on the components of the treatment plan as well as the timing of documents to ensure compliance with regulations.
Responsible party: Every week, the Executive Director teaches clinical components of residential treatment to the clinical department. The Executive Director inspects two charts per counselor per week. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of services on the individualized treatment and rehabilitation plan in 1 of 2 client records.
Client #13 was admitted on January 16, 2025 and successfully discharged on April 7, 2025. The individualized treatment and rehabilitation plan was developed on January 29, 2025. The individualized treatment and rehabilitation plan did not include the type and frequency of services.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director retrained clinical staff on the components of the treatment plan as well as the timing of documents to ensure compliance with regulations.
Responsible party: Every week, the Executive Director teaches clinical components of residential treatment to the clinical department. The Executive Director inspects two charts per counselor per 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, the facility failed to document counseling sessions on a regular and scheduled basis in 4 of 8 client records.
The facility policy states that clients are to receive individual counseling weekly and group therapy sessions daily. Clients #9, 10, 11 and 13 were not provided with individual sessions weekly.
Client #9 was admitted on March 3, 2025 and successfully discharged on April 9, 2025. Client #9 did not have any individual sessions documented for the weeks of March 16 & March 23, 2025.
Client #10 was admitted on March 3, 2025 and successfully discharged on April 2, 2025. Client #10 did not have any individual sessions documented for his entire treatment episode.
Client #11 was admitted on March 13, 2025 and successfully discharged on April 10, 2025. Client #11 did not have any individual sessions documented for the weeks of March 16 & March 23, 2025.
Client #13 was admitted on January 16, 2025 and successfully discharged on April 7, 2025. Client #12 did not have any individual sessions documented for the weeks of February 2, March 9, 16 & 23, 2025.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Counseling staff was re-educated on the proper documentation of weekly counseling sessions as well as weekly group counseling sessions.
Responsible party: Executive Director audits two charts per counselor per week to ensure compliance.
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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, the facility failed to document an aftercare plan in 5 of 5 client records.
Client #9 was admitted on March 3, 2025 and successfully discharged on April 9, 2025. There was no discharge summary in client record #9.
Client #10 was admitted on March 3, 2025 and successfully discharged on April 2, 2025. There was no aftercare plan in client record #10.
Client #11 was admitted on March 13, 2025 and successfully discharged on April 10, 2025. There was no aftercare plan in client record #11.
Client #12 was admitted on February 26, 2025 and successfully discharged on March 21, 2025. There was no aftercare plan in client record #12.
Client #13 was admitted on January 16, 2025 and successfully discharged on April 7, 2025. There was no aftercare plan in client record #13.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
We hired a Discharge Coordinator. The Discharge Coordinator meets individually with every patient and secures their aftercare prior to discharge. Each patient receives discharge instructions with their appointments on it prior to discharge.
Responsible party: Discharge Coordinator with Executive Director overseeing charts weekly to ensure compliance. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in 5 of 7 client records.
Client #7 was admitted on March 26, 2025 and discharged on April 3, 2025. There was no discharge summary in client record #7.
Client #10 was admitted on March 3, 2025 and discharged on April 2, 2025. There was no discharge summary in client record #10.
Client #11 was admitted on March 13, 2025 and discharged on April 10, 2025. There was no discharge summary in client record #11.
Client #12 was admitted on February 26, 2025 and discharged on March 21, 2025. There was no discharge summary in client record #12.
Client #13 was admitted on January 16, 2025 and discharged on April 7, 2025. There was no discharge summary in client record #13.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director teaches clinical components of residential treatment to the clinical department weekly. Discharge planning and summaries have been a component of it.
Responsible party: The Executive Director inspects two charts per counselor per week.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up contact, as per facility policy, in 5 of 6 client records.
The facility policy states that clients will receive follow up contact 7 days post discharge. Clients #9, 10, 11, 12 and 13 did not have documentation of a 7 day post discharge follow up.
Client #9 was admitted on March 3, 2025 and discharged on April 9, 2025. There was no 7-day post discharge follow up in client record #9.
Client #10 was admitted on March 3, 2025 and discharged on April 2, 2025. There was no 7-day post discharge follow up in client record #10.
Client #11 was admitted on March 13, 2025 and discharged on April 10, 2025. There was no 7-day post discharge follow up in client record #11.
Client #12 was admitted on February 26, 2025 and discharged on March 21, 2025. There was no 7-day post discharge follow up in client record #12.
Client #13 was admitted on January 16, 2025 and discharged on April 7, 2025. There was no 7-day post discharge follow up in client record #13.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
5.A designated staff member will contact the patient 7 days post discharge, complete a questionnaire with them, and document the communication in our follow up log.
Responsible party: An Intake Staff member will follow up via the phone 7 days post discharge and record their contact or attempts to contact. Monitored by Treatment Tech Supervisor monthly. |
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.
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Observations
Based on staff interviews, client interviews and a review of client records, the facility failed to document work done at the facility as an integral part of their treatment and rehabilitation plan.
It was reported that 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.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Counselors were reeducated on the importance of adding client chores to their treatment plan. Our IT department fixed our EHR so that these could be added.
Responsible party: Weekly chart audits done by Executive Director to ensure 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 the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the purchasing of food and equipment.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
This is a repeat deficiency from the January 23, 2024 annual licensing inspection.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.54.
Responsible party: Kitchen staff inspects weekly.
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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 the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the receiving, storing and preserving of food stuff.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.54 including receiving, storing, and preserving of food stuff.
Responsible party: Kitchen staff inspects weekly. |
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 the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included the proper preparation of food.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.54 including receiving, proper preparation of food.
Responsible party: Kitchen staff inspects weekly. |
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 the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.54 including safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
Responsible party: Kitchen staff inspects weekly. |
709.54(a)(5) LICENSURE Personal hygiene
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:
(5) Personal hygiene for those in food preparation areas.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included personal hygiene for those in food prepartation areas.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.54 including personal hygiene for those in food preparation areas.
Responsible party: Kitchen staff inspects weekly. |
709.54(a)(6) LICENSURE Special dietary needs
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:
(6) Special dietary needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document policies and procedures for dietetic services, which included special dietary needs.
Prior to this inspection, the facility had utilized an outside food service company with daily meal delivery. The facility recently began onsite food preparation.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual has been updated to include all components of regulation 709.54 including special dietary needs.
Responsible party: Kitchen staff inspects weekly; receives information from intake and nursing and documents it on the white board in the kitchen. |