INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2022, 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 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of four personnel records, the facility failed to ensure one applicable counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #4 was hired on July 18, 2022 as a counselor assistant. Employee #4 has a bachelor ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Employee #4 did not receive close supervision from July 2022 to November 2022. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. " The documented weekly supervision notes did not include documentation of direct supervisor or formal case reviews.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 3, 2021 licensing inspection.
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Plan of Correction
The facility will correct this deficiency by changing the current supervision document being used to include a formal documented case review and an additional hour of direct observation by a Clinical Supervisor of the Counselor Assistant once a week.
The Clinical Supervisor will schedule a training on counselor assistant supervision with the Counselor Assistant, Business/ Operations Manager, and Facility Director to ensure appropriate counseling and documentation is taking place.
The Clinical Supervisor will monitor Counselor Assistant supervision notes by having a case consult with the Counselor Assistant that is documented in the weekly supervision notes and is also reflected in the client's chart.
The Clinical Supervisor will provide direct observation and formal case reviews with the Counselor Assistant and have a weekly log completed to support this.
The Business/ Operations Manager will be responsible and monitor the above actions are being done to avoid this from recurrence.
The corrective action will be completed by December 28, 2022. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on December 7, 2022, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The dumpster in the facility parking lot by the designated smoking area was uncovered at the start of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Rehabilitation Technician Supervisor added surveillance of the security of the dumpster to the existing rehab tech daily shift checklist. Training was provided on the surveillance and documentation of the security of the dumpster. Rehab techs will also monitor security during the twelve daily client "fresh air" breaks held in the designated smoking area. Rehabilitation Tech Supervisor will monitor surveillance and checklist documentation on a daily basis. Remaining facility staff will also monitor on an ad hoc basis. Food and cleaning vendors were notified by the Facility Directors to close lid after each usage.
This corrective action plan was initiated and completed on December 28, 2022. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 written fire drill logs from February 2022 to November 2022, the facility failed to include the exit route used during two fire drills.
The February 21, 2022 and March 15, 2022 fire drill logs did not include the exit used for either fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drill log form was changed in April 2022 to include exit route and has been used going forward. Business/ Operations Manager is responsible for fire drills, log maintenance, and log documentation. Facility Director verified the change in fire drill log to include the exit used. Staff was informed that exit route documentation will be a part of the fire drill log, and was not included in two fire drills last year. All fire drills occurring after March 15, 2022 documented the exit route. Business/ Operations Manager is responsible for planning and documenting all aspects of the fire drills. Facility Director will review log after each fire drill to ensure completion of documentation.
This corrective action was instituted on December 28, 2022. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records, the facility failed to notify clients of their right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. As well as no client may be deprived of a civil right solely by reason of treatment in all seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Business/ Operations Manager added the following verbiage to client rights admission document located in EHR Kipu:
"Retain civil rights and liberties except as provided by statute. As well as no client may be deprived of a civil right solely by reason of treatment." Twenty civil rights were specified and the client attested to knowledge of this information.
This form is generated in the EHR Kipu for every client upon admission.
Business/ Operations Manager will provide oversight for each admission and insure that this verbiage is a part of their Clients Rights form.
This corrective action was instituted on December 28, 2022.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records, the facility failed to notify clients that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion in all seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 3, 2021 and February 10, 2021 licensing inspections.
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Plan of Correction
Business/ Operations Manager added the following verbiage to client rights admission document located in EHR Kipu:
"All clients have the right to receive treatment without being discriminated against in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion."
This form is generated in the EHR Kipu for every client upon admission. Each client attests that they are informed of their client rights upon admission.
Business/ Operations Manager will provide oversight for each admission and insure that this verbiage is a part of their Clients Rights form.
This corrective action was instituted on December 28, 2022. |
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 notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project and include the reason for termination in one applicable record reviewed.
Client #3 was admitted on November 4, 2022 and involuntarily terminated on November 17, 2022. There was documentation of the client attending a case consultation regarding their termination however there was not a notification in writing in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor devised written form to inform client of a decision to involuntarily terminate the client's treatment with the reason for termination. Two copies of this form will be generated: one for the client's chart and one for the client.
The involuntary termination will be discussed and documented by the Clinical Supervisor/ Counselor/ Assistant Counselor in the case conference following the termination. Training of the clinical staff and compliance will be monitored by the Clinical Supervisor.
This corrective action plan was initiated on December 28, 2022. |
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 both personnel and client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for documenting that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion was submitted and approved by the Department for the August 3, 2021 and February 10, 2021 licensing inspections. Notifying clients, they may not be discriminated against in the provision of services on the basis of ethnicity, marital status, sexual orientation, handicap or religion was again found to be a deficiency in the December 7, 2022 licensing inspection.
A plan of correction for completing and documenting close supervision for counselor assistants was submitted and approved by the Department for the August 3, 2022 licensing inspection. Supervision of counselor assistants was again found to be a deficiency in the December 7, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Business/Operations Manager will be responsible for ensuring corrective action is implemented and does not reoccur.
Facility Director is responsible for continually monitoring all plans of correction moving forward beginning December 28, 2022. |