INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7-8, 2023 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on one of one applicable employee personnel records reviewed, the facility failed to provide documentation of at least two years of experience or the completion of a core curriculum in clinical supervision for employee # 2.
Employee # 2 was hired as a clinical supervisor on May 1, 2022 and was still in this position at the time of the inspection. Based on employee # 2's resume, there was no documentation of at least two years of experience or the completion of a core curriculum in clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will complete the next available approved DDAP clinical supervision training. The Clinical Supervisor requested a list of acceptable supervisor trainings from DDAP to completed. The clinical supervisor will continue to receive documented Bi-weekly supervision from the Executive Director until the supervision training is completed. Clear Days Human Resource Manager and Executive Director will prescreen all potential candidates assuring the candidate has all the required training to fulfill the position. |
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 assigned tasks during emergencies upon employment.
Employee # 5 was hired as a counselor on October 5, 2022 and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was documented to have occurred until January 19, 2023.
Employee # 6 was hired as a counselor on November 2, 2022 and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was documented to have occurred until December 17, 2022.
Employee # 7 was hired as a counselor on December 7, 2022 and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was documented to have occurred until January 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new employees' will be trained to perform assigned task during emergencies by our Office Manager within seven days of hire. Documented proof of the training will be in employees training file.
The Executive Director and Offer Manager will conduct audits on personal and training files monthly to ensure all new employees are in compliance with Clear Days personal policies and procedures. |
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 facility policy and procedure manual and client records, the facility failed to provide documentation of an emergency contact notification after client left against medical advice in client record #5 and, a review of grievances filed on October 12, October 16, October 19, November 12 and November 30, 2022 the facility did not follow the grievance procedure in providing a resolution within five days of grievance filed.
Client # 5 was admitted on November 10, 2022 and discharged on December 28, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor reviewed AMA Emergency Contact Notification policy and procedure with staff. Clinical Supervisor will monitor documentation of all AMA discharges.
Grievance policy was reviewed with Clear Day staff. All grievances will be addressed, resolved and documented within 5 days, per Clear Day policy by clinical or executive director. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom the disclosure is being made.
Client # 2 was admitted on January 2, 2023 and was still active at the time of the inspection. Two informed and voluntary consents from the client for the disclosure of information dated January 2, 2023 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 3 was admitted on January 9, 2023 and was still active at the time of the inspection. Two informed and voluntary consents from the client for the disclosure of information dated January 9, 2023 did not provide the name of the person, agency or organization to whom the disclosure is being made.
Client # 6 was admitted on October 25, 2022 and was discharged December 5, 2022. An informed and voluntary consents from the client for the disclosure of information dated October 25, 2022 did not provide the name of the person, agency or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 17, 2022 annual licensing inspection.
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Plan of Correction
Clear Day's Clinical Supervisor conducted a in house training on completing informed and voluntary consent for disclosure of information contained in patient records. On orientation new staff members will be trained on completing informed and voluntary consent for disclosure of information contained in patient records. The Clinical Supervisor and Director of Nursing, and Intake Coordinator will monitor the files weekly ensuring documentation on consents are done properly. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 2 was admitted on January 2, 2023 and was still active at the time of the inspection. Three informed and voluntary consents from the client for the disclosure of information dated January 2, 2023 did not provide the specific information disclosed.
Client # 3 was admitted on January 9, 2023 and was still active at the time of the inspection. An informed and voluntary consents from the client for the disclosure of information dated January 9, 2023 did not provide the specific information disclosed.
Client # 6 was admitted on October 25, 2022 and was discharged December 5, 2022. An informed and voluntary consents from the client for the disclosure of information dated October 25, 2022 did not provide the specific information disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 17, 2022 annual licensing inspection.
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Plan of Correction
Clear Day's Clinical Supervisor conducted a in house training on completing informed and voluntary consent for disclosure of information contained in patient records. On orientation new staff members will be trained on completing informed and voluntary consent for disclosure of information contained in patient records. The Clinical Supervisor and Director of Nursing, and Intake Coordinator will monitor the files weekly ensuring documentation on consents are done properly. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 2 was admitted on January 2, 2023 and was still active at the time of the inspection. Three informed and voluntary consents from the client for the disclosure of information dated January 2, 2023 did not provide the purpose of the disclosure.
Client # 3 was admitted on January 9, 2023 and was still active at the time of the inspection. An informed and voluntary consents from the client for the disclosure of information dated January 9, 2023 did not provide the purpose of the disclosure.
Client # 6 was admitted on October 25, 2022 and was discharged December 5, 2022. An informed and voluntary consents from the client for the disclosure of information dated October 25, 2022 did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clear Day's Clinical Supervisor conducted a in house training on completing informed and voluntary consent for disclosure of information contained in patient records. On orientation new staff members will be trained on completing informed and voluntary consent for disclosure of information contained in patient records. The Clinical Supervisor and Director of Nursing, and Intake Coordinator will monitor the files weekly ensuring documentation on consents are done properly. |
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 one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in client record # 7.
Client # 7 was admitted on October 27, 2022 and discharged on November 28, 2022. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff were retraining on administrative discharge procedures. This is to ensure the client has been made aware in writing the decision and reason for termination. The Clinal Supervisor will oversee all involuntary discharges to ensure proper documentation is completed. |
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 three of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within one week for a referral and seven days, thirty days, and sixty days, after discharge.
Client # 5 was admitted on November 10, 2022 and was discharged on December 28, 2022. There were no follow-ups documented in the client record.
Client # 6 was admitted on October 25, 2022 and was discharged December 5, 2022. There were no follow-ups documented in the client record.
Client # 7 was admitted on October 27, 2022 and discharged on November 28, 2022. There were no follow-ups documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 17, 2022 annual licensing inspection.
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Plan of Correction
The counselors have been made aware to conduct a seven day follow up call to patients regardless of discharge status. The verified call will be documented in the patient file. The clinical supervisor will monitor and verify follow up calls are being conducted and documented. |