INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3-4, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clearvision Health and Wellness -Hazelton 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure the hot water temperature did not exceed 120 sink in the woman ' s bathroom on the 3rd floor read at a temperature of 151.5, the women ' s shower room on the 3rd floor read at a temperature of 167.9, the men ' s bathroom on the 3rd floor read at a temperature of 136, the men ' s 3rd floor shower room read at a temperature of 150.3, the men ' s 1st shower room on the 4th floor read at a temperature of 137.1, and the men ' s 2nd shower room on the 4th floor read at a temperature of 147 when tested during licensing process.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
The day following the inspection our maintenance man lowered the temperature on all three water heaters. He waited a day to allow it to cycle through and it still read high, so he lowered it once again. After waiting a day, several different areas were checked, and all readings were between 112 and 118. It appeared that when our contracted service work was done, the settings must have been adjusted. It will continue to be monitored three times a week until the end of the year to ensure it remains in range. Then going forward the maintenance man will be checking the water temperature weekly to assure it remains in the proper range. He will inform the Executive Director of his findings. Doing this will allow us to fix the problem immediately if it happens again. |
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 review of administrative paperwork, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving physical assault of a client by a client.
A review of inpatient non-hospital client record indicated a client was terminated from the program on August 24, 2025 due to physically assaulting another client. This was not documented in the facility ' s unusual incident log nor was the unusual incident reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A memo was sent to staff remining them of the importance of reporting whenever something out of the ordinary occurs. Staff was also informed that in addition to adding the information to their shit report, they should also put it in our team's communication to add additional visibility. This process will be reevaluated before the end of the year to see if it is working or if any changes need to be made. Going forward the executive director will review both the shift reports and the team's communication to check if any reportable events occurred so the report can be completed. A report was submitted for the incident that was missed on 1/12/2026. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on the review of detox client records, the project failed to document a complete client record on an individual that included follow-up information within 7 days, per facility policy, in one of one applicable client records reviewed.
Client #6 was admitted to the detox program on August 25, 2025 and discharged on August 28, 2025. Follow up information was to be documented by September 4, 2025; however, there was no follow up information documented in record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A system has been put in place where a spreadsheet is kept with all discharge information. It is a shared spreadsheet created by the clinical supervisor. Calls will be made based on the information in that spreadsheet. When calls are made a form will be completed in our EMR. The follow up form will be in each client's record once the call is completed. When the call is completed, the clinical supervisor will be made aware by it being documented on the spreadsheet. The staff was trained in this procedure and began following it, 12/22/25. A call was placed to client #6 on 12/08/25 and documented in the client's chart. The follow ups will be reviewed periodically by the executive director to ensure calls are being completed on the dates necessary going forward. The director checked that the calls were being made correctly on 12/31/25 and will continue to be monitored. |
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 the review of inpatient non-hospital client records, the project failed to document a complete client record on an individual that included follow-up information within 30 days, per facility policy, in four of four applicable client records reviewed.
Client #8 was admitted to the inpatient non-hospital program on August 21, 2025 and discharged on September 19, 2025. Follow up information was to be documented by October 19, 2025; however, it was not documented until December 2, 2025.
Client #9 was admitted to the inpatient non-hospital program on June 5, 2025 and discharged on July 3, 2025. Follow up information was to be documented by August 3, 2025; however, it was not documented until November 24, 2025.
Client #10 was admitted to the inpatient non-hospital program on September 2, 2025 and discharged on September 8, 2025. Follow up information was to be documented by October 8, 2025; however, it was not documented until November 2, 2025.
Client #11 was admitted to the inpatient non-hospital program on August 6, 2025 and discharged on August 24, 2025. Follow up information was to be documented by September 24, 2025; however, it was not documented until October 17, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A system has been put in place where a spreadsheet is kept with all discharge information. It is a shared spreadsheet created by the clinical supervisor. Calls will be made based on the information in that spreadsheet. When calls are made a form will be completed in our EMR. The follow up form will be in each client's record once the call is completed. When the call is completed, the clinical supervisor will be made aware through documentation on the spreadsheet. The follow ups will be reviewed periodically by the executive director to ensure calls are being completed on the dates necessary. |