INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2023, 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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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 the review of client records, the facility failed to follow their policy to contact a client's emergency contact within twelve hours of leaving against medical advice in one out of one applicable record reviewed.Client #6 was admitted on October 31, 2023 and left against medical advice on November 1, 2023. There was no documentation that the emergency contact had been notified. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a client leaves AMA it is our policy to notify the emergency contact, this is usually done with the client before they leave. Client #6 was missing documentation of this call. All staff will have the policy reviewed with them and the procedure of documenting the call will also be reviewed with all staff so everyone is aware of how and where to document this call. All staff will have this review completed by 1/5/2024. Going forward the executive director will review all discharged charts to assure that this call has been documented. |
709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary per the facility ' s policy and procedures manual within seventy-two hours of discharge in one out of one applicable record reviewed.Client #6 was admitted on October 31, 2023 and was discharged on November 1, 2023. The discharge summary was completed on November 30, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The client's counselor is responsible for completing the discharge summary within 72 hours of discharge. When client #6 was discharged her counselor was not available, the personal responsible for covering did not complete the work that was required of her and is no longer with the facility. The importance of assuring that discharged summaries are completed has been reviewed with all of the current counselors. The reviews were completed by 1/5/2024. Going forward the executive director will review all discharged charts to assure the discharge summary has been completed within 72 hours. |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on an administrative review and client records, the facility failed to notify the Department within 90 days of the occurrence of any of change of activity. The facility was prescribing buprenorphine to clients in the detoxification activity without notifying the Department of the use of other chemotherapy at the facility. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility has applied to have the license updated to include other chemotherapy. The application has been approved and we have received our letter of approval with an effective date of 12/22/23. Going forward and and all changes will be sent to DDAP for approval by the executive director in the time allowed. |