INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2021 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the project ' s policy and procedures manual, the project failed to develop a written policy on the recruitment and hiring staff persons who are appropriate to the population to be served. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has made appropriate updates to its Staffing policy to include its commitment to make every effort to hire staff representative of the populations it serves. |
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 project ' s policy manual, the project failed to develop a written policy on staff development that includes an assessment of the staff training needs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has made the appropriate updates to its Ongoing Training and Development policy to reflect its established ongoing needs assessment of all employees and staff to ensure ongoing staff development. The policy has been updated to reflect the established individual roles that are responsible for staff development and training as well as the time frames for completion of these assessments of staff training needs. |
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 the review of personnel files, the facility failed to develop a written individual training plan for one out of one employees.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Ongoing Training and Development policy to reflect its current practice that ongoing needs assessments of all employees are based on their performance deficiencies, policy and procedure compliance, and revisions. Training needs will be identified and requested by managers to the corresponding departments (Learning and Development, Lab Trainers and/or Provider Preceptors). Once the request has been sent, the corresponding department will coordinate training efforts with the employee. The employee is expected to complete the required trainings within 60 days of enrollment or as determined by CleanSlate management. Feedback and reporting will be provided by management to the employee once training has been completed. |
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 review of the facility's fire drill log from October 2020 through July 2021, the facility failed to maintain a written fire drill record including the exit route used for the months of March 2021, May 2021, and June 2021 and whether the fire alarm or smoke detector was operative during the fire drills for the months of October, November, and December 2020 and January February, March, May, June, and July of 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its internal Fire Drill log to include documentation for exit route used and fire alarm or smoke detector utilization during fire drills. Education has gone out to all facilities to include this documentation as they conduct their facility fire drills. |
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 review of the facility's fire drill log from October 2020 through July 2021, the facility failed to set off the fire alarm or smoke detector during the months of October, November and December of 2020, January, February, March, May, June, and July of 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its internal Fire Drill log to include documentation for the activation of fire alarm or smoke detector during an active fire drill. Education has gone out to all facilities to include this documentation as they conduct their fire drills.
In the event that a facility is located in a multi-office building, hand-held alarm devices shall be used in place of building-wide smoke detectors or building-wide fire alarms. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written policy on the utilization of volunteers. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate does not utilize volunteers within its program. CleanSlate has updated its Workforce Planning policy to reflect that recruitment strategies do not include volunteers and/or interns. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written policy and implement procedures to respond to physical assault or sexual assault by staff or a client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy reflect how CleanSlate shall respond to a physical or sexual assault by staff or a client.
Response includes generation of internal event report, reporting structure internally, reporting to appropriate authorities and conducting its own internal investigation with the development of corrective actions with established timelines as appropriate.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written policy and implement procedures to respond to selling or use of illicit drugs on the premises. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy reflect how CleanSlate shall respond to confirmed selling or use of illicit drugs on the premises.
Response includes generation of internal event report, reporting structure internally, reporting to appropriate authorities and conducting its own internal investigation with the development of corrective actions with established timelines as appropriate. As part of the response, a patient that has been confirmed to be selling or using illicit drugs on the premises may be discharged/transferred to a higher level of care by way of warm handoff.
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written policy and implement procedures to respond to theft, burglary, break in or similar incident at the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy reflect how CleanSlate shall respond to a theft, burglary, break-in or similar incident at the facility.
Response includes generation of internal event report, reporting structure internally, reporting to appropriate authorities and conducting its own internal investigation with the development of corrective actions with established timelines as appropriate.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written policy and implement procedures to respond to an event at the facility requiring the presence of police, fire, or ambulance personnel. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy reflect how CleanSlate shall respond to an event that requires the presence of police, fire, or ambulance personnel at the facility.
Response includes generation of internal event report, reporting structure internally, reporting to appropriate authorities and conducting its own internal investigation with the development of corrective actions with established timelines as appropriate.
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written policy and implement procedures to respond to fire or structural damage to the facility.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy reflect how CleanSlate shall respond to fire or structural damage to the facility.
Response includes the implementation of the All Hazards Plan procedures, the generation of internal event report, reporting to appropriate authorities and conducting its own internal investigation with the development of corrective actions with established timelines as appropriate.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written policy and implement procedures to respond to outbreak of a contagious disease requiring for Centers for Disease Control (CDC) notifications. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy to include procedures to respond to an outbreak of a contagious disease requiring for CDC notification. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a policy that includes the procedures on how the facility will document an unusual incident. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy reflect how CleanSlate shall document an unusual incident.
Response includes the generation of internal event report, reporting incident to internal chain of command, reporting to appropriate authorities if appropriate and conducting its own internal investigation with the development of corrective actions with established timelines as appropriate.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the project ' s policy manual, the facility failed to develop a policy that includes the procedures on how the project will provide prompt review and identification of the causes directly or indirectly responsible for the unusual indecent.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy reflect how CleanSlate will provide prompt review and identification of causes directly or indirectly responsible for the unusual incident.
CleanSlate has an established internal event reporting system. All unusual incidents and other occurrences are entered into the ERS and are monitored by the Medical Affairs & Regulatory team on a daily basis. An internal event report triggers the mechanism for operational, clinical and regulatory leaders to review and investigate all events reported in the system.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the project ' s policy and procedure manual the project failed to develop a policy that describes implementation of a timely and appropriate corrective action plan when indicated.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has updated its Mandatory Reporting policy to describe the implementation of timely and appropriate corrective action plans when necessary.
CleanSlate has updated its Mandatory Reporting policy to describe how the ongoing monitoring of the corrective action plans are accomplished.
Should a corrective action plan be developed, documentation of such is updated accordingly and maintained within the occurrence event report within CleanSlate's electronic Reporting System. Corrective actions are monitored by the Medical Affairs & Regulatory Team on an ongoing basis.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the project ' s policy manual the project failed to develop a policy that describes how the facility will provide ongoing monitoring of the corrective action plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Should a corrective action plan be developed, documentation of such is updated accordingly and maintained within the occurrence event report within CleanSlate's electronic Reporting System. Corrective actions are monitored by the Medical Affairs & Regulatory Team on an ongoing basis. |
709.91(a)(1) 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:
(1) Criteria for admission.
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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 criteria for admission. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has established the Behavioral Health Assessment policy to address and to define the parameters of Behavioral Health Assessment services at CleanSlate through the utilization of the ASAM dimensions related to emotional/psychological, medical and social histories. |
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. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has an established Clinical Matrix that includes Medication Assisted Treatment methodology, incorporating behavioral health. CleanSlate has an established Patient Initial Screening and Waitlist policy that addresses initial intake. The Initial Assessment of the Person Served policy addresses admission and treatment methodology. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the project ' s policy manual, the project failed to develop a written client follow up policy. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate has established two policies to address patient follow-up.
The CleanSlate Aftercare policy addresses that all patients that are discharged from CleanSlate will be provided with aftercare plan; all patient's are encouraged to participate in an aftercare plan that includes the patient's preferred method for follow-up post-discharge. Information regarding referrals or aftercare services are documented within the electronic medical record of the patient.
The CleanSlate Post-Discharge Evaluation policy addresses the process in which CleanSlate obtains vital information from patients related to their post-discharge outcomes and feedback regarding program improvement to improve quality of care at CleanSlate.
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