INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CleanSlate Medical Group of Pennsylvania, LLC 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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704.11(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 administrative records, the facility failed to complete an assessment of the staff training needs for 2022 training year.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate Centers has established a process for ensuring the Project Director develops a comprehensive staff development program for personnel in collaboration with the organization's Learning & Development department including policies & procedures indicating who is responsible & the timeframes for completion of an annual assessment of staff training needs for each training year.
This assessment of staff training needs shall be completed at the beginning of each training year.
An internal meeting has been scheduled to review plans for fulfilling this regulatory requirement on 8/1/2022.
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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 administrative records, the facility failed to complete an overall plan to address staff training needs for 2022 training year. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate Centers has established a process for ensuring the Project Director develops a comprehensive staff development program for personnel in collaboration with the organization's Learning & Development department including policies & procedures indicating who is responsible & the timeframes for completion of an annual overall plan addressing staff training needs for each training year.
This overall training plan shall be established at the beginning of each training year.
An internal meeting has been scheduled to review plans for fulfilling this regulatory requirement on 8/1/2022.
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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 comprehensive staff development program, the facility failed to develop an evaluation of the overall training plan for 2021 training year. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate Centers has established a process for ensuring the Project Director develops a comprehensive staff development program for personnel in collaboration with the organization's Learning & Development department including policies & procedures indicating who is responsible & the timeframes for completion of an annual evaluation of the overall training plan for each training year.
This evaluation of the overall training plan shall be completed at the end of each training year.
An internal meeting has been scheduled to review plans for fulfilling this regulatory requirement on 8/1/2022.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of two personnel records, the facility failed to document a written training plan for each employee, appropriate to that employee's skills level, shall be developed annually with input from both the employee and supervisor in both personnel records reviewed. Employee #1 was hired on February 4, 2022 as the Project Director and was still in that position at the time of the inspection. Employee #2 was hired on February 22, 2021 as the Facility Director and was still in that position at the time of the inspection. This is a repeat citation from August 24, 2021 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate Centers has established a process for ensuring that a written individual training plan for each employee be developed annually as part of its staff development program. These training plans shall include input from both the employee & the supervisor.
Initial focus will be placed on establishing annual written individual training plans for the Project Director & the Facility Director. These training plans will be made available for review & verification in the employees' personnel records.
These individual training plans shall be established at the beginning of each training year.
An internal meeting has been scheduled to review plans for fulfilling this regulatory requirement on 8/1/2022.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 ensure that employee #1 was trained in the use of a fire extinguisher.Employee#1 was hired on February 4, 2022 as a Project Director and was still in that position at the time of the inspection. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate Centers shall ensure that future personnel records for this facility reflect the training of Employee #1 on the use of a fire extinguisher.
Employee #1 was assigned this training in our electronic learning management system which was completed on 6/10/2022 via a course entitled 'All Hazards & Continuity of Operations (COOP) Emergency Planning Training'.
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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 the facility's fire drill logs from September 2021 through May 2022, the facility failed to include on the fire drill record if the fire alarm or smoke detector was operative at the time of the drill. This is a repeat citation from the August 24, 2021 licensing inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Pursuant to the Division of Drug & Alcohol Program Licensing Alert 4-97: Requests for Exceptions to Regulations, Part V. Drug & Alcohol Activities, Chapter 701 ? CleanSlate Centers is in the process of formally requesting a waiver for exception to be granted that exempts this licensed facility from the regulatory requirement for indicating on monthly fire drill completion report forms that the fire alarm or smoke detector was operative at the time of the drill.
Formal letter requests have begun to be submitted as of 7/14/2022 & are currently pending a response & decision.
The facility will attempt alternate means in the interim to fulfill this regulatory requirement including reaching out to the local fire department to ensure this deficit does not occur again until the request for the waiver is approved.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill logs, the facility failed to set off the fire alarm or smoke detector during the fire drills from September 2021 through May 2022. This is a repeat citation from the August 24, 2021 licensing inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Pursuant to the Division of Drug & Alcohol Program Licensing Alert 4-97: Requests for Exceptions to Regulations, Part V. Drug & Alcohol Activities, Chapter 701 ? CleanSlate Centers is in the process of formally requesting a waiver for exception to be granted that exempts this licensed facility from the regulatory requirement for setting off the fire alarm or smoke detector during each monthly fire drill that is conducted.
Formal letter requests have begun to be submitted as of 7/14/2022 & are currently pending a response & decision.
The facility will attempt alternate means in the interim to fulfill this regulatory requirement including reaching out to the local fire department to ensure this deficit does not occur again until the request for the waiver is approved.
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709.91(a)(2) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(2) Treatment methodology.
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Observations
Based on a review of the project's policy manual, the project failed to develop a written plan providing for intake and admission which includes treatment methodology.This is a repeat citation from the August 24, 2021 licensing inspection. This finding was reviewed with the facility staff during licensing process.
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Plan of Correction
CleanSlate Centers has established with the Project Director (CleanSlate Centers Director of Behavioral Health) a new policy entitled 'Behavioral Health Counseling Treatment Methodologies'.
The purpose of this policy is to define the therapeutic treatment methodologies that are utilized by licensed professional counselors at CleanSlate Centers outpatient treatment programs when providing counseling for substance use disorders & co-occurring disorders to Patients.
Based on the needs of each Patient upon intake & admission, CleanSlate Centers provides or arranges for individual &/or group counseling/therapy.
In providing these behavioral health services directly, counselors at CleanSlate Centers utilize therapeutic treatment methodologies that include but are not limited to the following ? Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), Dialectical Behavior Therapy (DBT) & Trauma-Focused Therapies.
This policy shall be applicable once CleanSlate Center locations in the state of Pennsylvania begin providing Patients directly with drug & alcohol counseling.
This policy has been drafted as of 7/15/2022 & is pending final review & approval by our Compliance Management Committee.
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