INITIAL COMMENTS
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This report is a result of an on-site licensure provisional renewal inspection conducted on September 2-3, 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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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.
During the physical plant inspection, DDAP staff observed the following:
picnic table in the facility courtyard was damaged and needs repaired/replaced.
bedroom #10, burn marks on the outlet cover
men ' s lounge damaged drywall
men ' s lounge light switch is missing a cover.
entrance reception area ceiling tile damaged
residential hallway, near rehab nursing/medication area, Thermostat missing cover
bedroom #21 broken door return mechanism
bedroom #23 water damaged ceiling needs repaired
' s detox bathroom severely damaged ceiling and paint.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the February 28, 2025, May 2, 2025, and July 9, 2025, onsite inspections.
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Plan of Correction
1. Toni Harris, Executive Director, will contract with a licensed maintenance vendor to conduct a full physical plant assessment and complete all identified repairs by December 30, 2025.
2. Specific repairs to be completed:
o Replace/repair damaged picnic table in courtyard.
o Replace burn-marked outlet cover in bedroom #10.
o Repair damaged drywall in men's lounge.
o Install missing light switch cover in men's lounge.
o Replace damaged ceiling tile in entrance reception area.
o Install thermostat cover in residential hallway near rehab nursing/medication area.
o Repair broken door return mechanism in bedroom #21.
o Repair water-damaged ceiling in bedroom #23.
o Repair severely damaged ceiling and repaint detox bathroom.
3. Toni Harris, Executive Director, will implement a weekly physical plant inspection checklist to be completed by the Maintenance Supervisor and reviewed by the Executive Director every Monday.
4. All staff will be in-serviced on reporting physical plant hazards immediately to the Maintenance Supervisor.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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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.
DDAP staff observed that the first stall in the men ' s detox bathroom did not have a door.
This is a repeat deficiency from the May 2, 2025 and February 28, 2025 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will ensure a fully functional privacy door is installed on the first stall in the men's detox bathroom by a licensed contractor.
2. The Maintenance Supervisor will verify installation and test door functionality.
3. Toni Harris, Executive Director, will add daily bathroom privacy checks to the Environmental Rounds checklist.
4. All nursing and tech staff will be in-serviced on immediate reporting of privacy deficiencies.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and washrooms by exhaust fan or window. The ventilation fan in the bathroom in female detox toilet/washroom was inoperable.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will contract with a licensed HVAC technician to repair or replace the inoperable exhaust fan in the female detox bathroom.
2. The Maintenance Supervisor will test fan operation post-repair and document functionality.
3. Toni Harris, Executive Director, will add monthly ventilation system checks to the Maintenance Log.
4. Nursing staff will be trained to report ventilation issues immediately.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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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 training records, the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Staff #1 was hired as a tech on August 4, 2025. There was no documentation of emergency training in staff record #1.
Staff #2 was hired as a tech on August 4, 2025. There was no documentation of emergency training in staff record #2.
This is a repeat deficiency from the May 2, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Director of Nursing will schedule and conduct emergency response training for Staff #1 and Staff #2 (hired 8/4/2025).
2. Training will include what to do in all emergency situations including fire evacuation, emergency codes, and assigned duties, per our facility's policies.
3. Director of Nursing will implement a policy requiring emergency training within 7 days of hire for all new staff.
4. Human Resources will audit personnel files monthly to ensure 100% compliance with emergency training documentation.
Responsible Party: Director of Nursing
Completion Date: December 30, 2025
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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 that it the client, in writing, of the decision to involuntarily terminate the client's treatment at the project in one of two client records.
Client #7 was admitted to treatment on July 29, 2025 and involuntarily discharged on August 16, 2025. There was no documention that client was provided with a written notice of involuntary termination in client record #7.
This is a repeat deficiency from the May 2, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
of Correction:
1. Toni Harris, Executive Director, will revise the Involuntary Discharge Policy to mandate written notice with reason for termination.
2. A standardized "Notice of Involuntary Termination" form will be created and placed in the electronic health record.
3. All clinical staff will be in-serviced on the revised policy and form use.
4. Director of Nursing will audit 100% of involuntary discharges weekly to ensure written notice is provided and documented.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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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 that the client was given an opportunity to request reconsideration of a decision terminiating treatment in one of two client records.
Client #7 was admitted to treatment on July 29, 2025 and involuntarily discharged on August 16, 2025. There was no documention that client was provided with a written notice of involuntary termination, which included the opportunity to request reconsideration of the decision to terminate treatment in client record #7.
This is a repeat deficiency from the May 2, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will update the "Notice of Involuntary Termination" form to include a section on the right to request reconsideration within 48 hours.
2. The form will include contact information for the Clinical Director.
3. All staff will be trained on the reconsideration process.
4. Director of Nursing will track all reconsideration requests and outcomes in a log.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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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 administrative documentation, the facility failed to file a report with DDAP for an event at the facility requiring the presence of ambulance personnel.
It was documented that an ambulance was called to the facility on August 15, 2025 for a client medical emergency. There was no documentation that an unusual incident report was filed with DDAP for this event.
This is a repeat deficiency from the May 2, 2025 and February 28, 2025 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will implement an Unusual Incident Reporting Policy requiring immediate notification to the Clinical Director for any event involving ambulance or assault.
2. All unusual incidents, as well as, DDAP denoted unusual incidents will be reported and submitted within 3 business days.
3. Director of Nursing will review all ambulance calls and incident reports daily.
4. All staff will be in-serviced on the 3-day reporting requirement.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
The facility policy includes a procedure for follow up for clients that have an aftercare plan in place; however, there was no follow up policy for clients that have an unplanned discharge, such as involuntary termination, medical or against medical advice.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will revise the Follow-Up Policy to include procedures for unplanned discharges (involuntary, AMA, medical).
2. Policy will require follow-up contact within 5 business days for all discharge types.
3. Discharge planners will document follow-up attempts in the EHR.
4. Director of Nursing will audit 100% of discharges weekly for follow-up compliance.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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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 three days.
Client #2 was admitted on August 9, 2025, and was active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the client record.
Client #3 was admitted on July 14, 2025, and was active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the client record.
Client #4 was admitted on July 22, 2025, and was active at the time of the inspection. A treatment plan was due no later than July 25, 2025; however, it was not completed until August 1, 2025.
Client #6 was admitted on July 24, 2025, and discharged on August 21, 2025. A treatment plan was due no later than July 27, 2025; however, it was not completed until July 31, 2025.
Client #9 was admitted on June 13, 2025, and discharged on July 25, 2025. A treatment plan was due no later than June 16, 2025; however, it was not completed until July 10, 2025.
Client #10 was admitted on June 24, 2025, and discharged on August 7, 2025. A treatment plan was due no later than June 27, 2025; however, it was not completed until July 2, 2025.
This is a repeat citation from May 2, 2025, onsite inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
1. Director of Nursing will enforce the 3-day treatment plan policy.
2. Counselors will be assigned treatment plan completion within 72 hours of admission.
3. A daily Treatment Plan Tracker will be maintained by the Clinical Supervisor.
4. Director of Nursing will audit all admissions weekly for timely plan completion.
Responsible Party: Director of Nursing
Completion Date: December 30, 2025
Answers:
#2, #3, #4 are no longer active with us. All had individualized treatment plans.
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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 treatment of rehabilitation services on the individual treatment and rehabilitation plan in five of nine client records.
Client #6 was admitted on July 29, 2025 and discharged on August 21, 2025. The individualized treatment and rehabilitation plan was developed on July 31, 2025. There was no type and frequency documented on the individualized treatment plan documented in client record #6.
Client #7 was admitted on July 29, 2025 and discharged on August 16, 2025. The individualized treatment and rehabilitation plan was developed on August 2, 2025. There was no type and frequency documented on the individualized treatment plan documented in client record #7.
Client #8 was admitted on June 2, 2025 and discharged on June 12, 2025. The individualized treatment and rehabilitation plan was developed on June 4, 2025. There was no type and frequency documented on the individualized treatment plan documented in client record #8.
Client #9 was admitted on June 13, 2025 and discharged on July 25, 2025. The individualized treatment and rehabilitation plan was developed on July 10, 2025. There was no type and frequency documented on the individualized treatment plan documented in client record #9.
Client #10 was admitted on June 24, 2025 and discharged on August 7, 2025. The individualized treatment and rehabilitation plan was developed on July 2, 2025. There was no type and frequency documented on the individualized treatment plan documented in client record #10.
This is a repeat deficiency from the May 2, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will revise the treatment plan template to include mandatory fields for "Type of Service" and "Frequency."
2. All counselors will be in-serviced on completing these fields.
3. Clinical Supervisor will review 100% of treatment plans before signing.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within timeframes established by the facility ' s policy. The facility ' s policy notes treatment plans will be updated every fifteen days.
Client #4 was admitted on July 22, 2025, and was still active at the time of the inspection. A treatment plan was completed on August 1, 2025, and the next update was due no later than August 16, 2025; however, there were no further treatment plans documented in the client record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Director of Nursing will implement a 15-day Treatment Plan Update Calendar.
2. Counselors will be assigned updates due every 15 days from initial plan.
3. Clinical Supervisor will audit updates bi-weekly.
Responsible Party: Director of Nursing
Completion Date: December 30, 2025
Answers:
#4 did not receive a treatment plan update; they have been discharged.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #1 was admitted on August 3, 2025, and was active at the time of the inspection. A treatment plan dated August 7, 2025, noted that the client would receive one individual therapy session per week. During the week of August 11-August 16, 2025, there were no individual treatment sessions documented in the client record.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
1. Director of Nursing will implement a weekly Counseling Session Tracker.
2. Individual therapy sessions will be scheduled at admission per plan frequency.
3. Clinical Supervisor will verify session documentation within 24 hours.
Responsible Party: Director of Nursing
Completion Date: December 30, 2025
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include case consultation notes.
The policy and procedures manual notes that case consultations are completed every fifteen days.
Client #2 was admitted on August 9, 2025, and was active at the time of the inspection. There were no case consultation notes documented in the client record.
Client #3 was admitted on July 14, 2025, and was active at the time of the inspection. There were no case consultation notes documented in the client record.
Client #4 was admitted on July 22, 2025, and was active at the time of the inspection. There were no case consultation notes documented in the client record.
Client #6 was admitted on July 18, 2025, and discharged on August 21, 2025. There were no case consultation notes documented in the client record.
Client #7 was admitted on July 29, 2025, and discharged on August 16, 2025. There were no case consultation notes documented in the client record.
Client #9 was admitted on June 13, 2025, and discharged on July 25, 2025. There were no case consultation notes documented in the client record.
Client #10 was admitted on June 24, 2025, and discharged on August 7, 2025. There were no case consultation notes documented in the client record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
1. Director of Nursing will assign case consultations every 15 days via calendar reminder.
2. A Case Consultation Note template will be added to the EHR.
3. Clinical Supervisor will audit 100% of records bi-weekly.
Responsible Party: Director of Nursing
Completion Date: December 30, 2025
Answers:
#3 received a case consult, #4 did not
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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 a complete client record which included follow up information in five of five client records.
Facility policy states that follow up contact will be completed within 5 business days of discharge.
Client #6 was admitted on July 18, 2025 and discharged on August 21, 2025. There was no follow up contact documented in client record #6.
Client #7 was admitted on July 29, 2025 and discharged on August 16, 2025. There was no follow up contact documented in client record #7.
Client #8 was admitted on June 2, 2025 and discharged on June 12, 2025. There was no follow up contact documented in client record #8.
Client #9 was admitted on June 13, 2025 and discharged on July 25, 2025. There was no follow up contact documented in client record #9.
Client #10 was admitted on June 24, 2025 and discharged on August 7, 2025. There was no follow up contact documented in client record #10.
This is a repeat deficiency from the May 2, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will enforce the 5-day follow-up policy for all discharges.
2. Intake staff will document three attempts (phone, email, mail) within 5 days.
3. Director of Nursing will audit all discharges weekly.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
Answers:
Patients #1, 2, 3, 4, 5, and 6 all had follow ups completed.
Patient #7 was an admin discharge and refused all aftercare so no follow up was completed.
Patients #8, 9, and 10 did not have follow ups documented. |
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 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 planning.
It was reported that all clients are assigned work therapy tasks to complete as part of their treatment.
Client #1 was admitted on August 3, 2025, and was active at the time of the inspection. A treatment plan dated August 7, 2025, did not include work therapy as part of the treatment goals.
Client #4 was admitted on July 22, 2025, and was active at the time of the inspection. A treatment plan dated August 1, 2025, did not include work therapy as part of the treatment goals.
Client #6 was admitted on July 18, 2025, and discharged on August 21, 2025. A treatment plan dated July 31, 2025, did not include work therapy as part of the treatment goals.
Client #10 was admitted on June 24, 2025, and discharged on August 7, 2025. A treatment plan dated July 2, 2025, did not include work therapy as part of the treatment goals.
This is a repeat citation from the February 28, 2025, and May 2, 2025, onsite inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will revise the treatment plan to include a "Work Therapy" goal with specific tasks and frequency.
2. All clients will have work therapy documented on the plan within 3 days of admission.
3. Clinical Supervisor will verify inclusion on all plans by reviewing charts biweekly.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
Answers:
Patients #1 and #4 did not receive an amended treatment plan goal regarding work. And both were successfully discharged.
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709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
The facility policy includes a procedure for follow up for clients that have an aftercare plan in place; however, there was no follow up policy for clients that have an unplanned discharge, such as involuntary termination, medical or against medical advice.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will enforce the 5-day follow-up policy for all discharges.
2. Intake staff will document three attempts (phone, email, mail) within 5 days.
3. Director of Nursing will audit all discharges weekly.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for keeping the grounds of the facility clean, safe, sanitary and in good repair was submitted and approved by the Department for the May 2, 2025, and February 28, 2025 licensing inspections. Keeping the facility grounds clean, safe, sanitary and in good repair was again found to be a deficiency in the September 3, 2025 licensure inspection.
A plan of correction for providing privacy in bathrooms was submitted and approved by the Department for the May 2, 2025, and February 28, 2025 licensing inspections. Privacy in bathrooms was again found to be a deficiency in the September 3, 2025 licensure inspection.
A plan of correction for reporting required unusual incidents to DDAP within 3 business days was submitted and approved by the Department for the May 2, 2025, and February 28, 2025 licensing inspections. Reporting required unusual incidents to DDAP within 3 business days was again found to be a deficiency in the September 3, 2025 licensure inspection.
A plan of correction for documenting work therapy as an integral part of treatment plans was submitted and approved by the Department for the May 2, 2025, and February 28, 2025 licensing inspections. Documenting work therapy as an integral part of treatment plans was again found to be a deficiency in the September 3, 2025 licensure inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Toni Harris, Executive Director, will establish a DDAP Compliance Committee meeting bi-weekly to review all POC progress.
2. All repeat citations will be assigned to specific staff with weekly status reports.
3. A master POC tracking log will be maintained and submitted to DDAP monthly.
Responsible Party: Toni Harris, Executive Director
Completion Date: December 30, 2025
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