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 covermen ' s lounge damaged drywall men ' s lounge light switch is missing a cover. entrance reception area ceiling tile damagedresidential hallway, near rehab nursing/medication area, Thermostat missing coverbedroom #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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |
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
An approved Plan of Correction is not on file. |