INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16-17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wilkes-Barre Treatment LLC dba Clearbrook Treatment Centers 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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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, the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. Several trash cans win the kitchen and throughout the facility did not have lids.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/17/23 the maintenance team immediately went to the storage area and recovered the garbage lids to be placed on the garbage pail in the dining area and in the men's restroom. The head chef, kitchen staff, and maintenance were made aware of the licensing finding. Both departments will monitor and prevent any further deficiencies. For our monthly performance improvement meeting we have added a spot check to our operations audit, and the compliance and quality specialist will complete weekly walkthroughs to ensure garbage lids are properly in place. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored hanging on hooks and silverware was being stored in bins that were not covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/17/23 the maintenance team immediately went to the storage area and recovered a bin and lid to store the cooking utensils in. The head chef, and kitchen staff were made aware of the licensing findings. The kitchen staff will continue to utilize the closed bin to store the clean cooking utensils after they are washed and dried. For our monthly performance improvement meeting we have added a spot check to our operations audit, and the compliance and quality specialist will complete weekly walkthroughs to ensure that kitchen utilities are stored properly. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Cameras are in group rooms in the outpatient building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/17/23 the IT department was notified that the cameras must be removed from each group room promptly. All cameras have been removed accordingly. Leadership and the compliance specialist will continue to ensure confidentiality of group rooms. |
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 residential 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 # 6.
Client # 6 was admitted on October 31, 2022 and discharged on November 9, 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
On 2/20/23 the Clinical Director discussed the importance of documenting the decision to involuntarily terminate the client from the program. The therapist must discuss the decision with the client, document the reasoning of the decision, and ensure that the client acknowledges the right to appeal our decision. The QA department developed a specific form to utilize directly related to the decision to involuntarily terminate the client from the program. For our monthly performance improvement, the Clinical Director and Clinical Supervisor will identify 2 clients that were Administratively Discharged for review during the monthly chart audit committee meeting to ensure this process is being implemented. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on two of four applicable partial hospitalization client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every 30 days in client records # 1 and # 2.
Client # 1 was admitted on December 30, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 9, 2023. A treatment and rehabilitation plan update was due no later than February 9, 2023; however, a treatment and rehabilitation plan update did not occur until February 14, 2023.
Client # 2 was admitted on December 19, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 26, 2022. A treatment and rehabilitation plan update was due no later than January 26, 2023; however, a treatment and rehabilitation plan update did not occur until February 2, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/20/2023, the Clinical Director and the Clinical Supervisor met with the Primary Therapist of each client to discuss the importance and the purpose of the treatment plan update being done every 30 days and completing them on time. The Clinical Director and the Clinical Supervisor will monitor the census for upcoming clients reaching the 30-day mark to prevent the treatment plans being overlooked. The health information manager sends out a health information discrepancy report bi-weekly that monitors discrepancies in timeframes directly related to the master treatment plan update. This tool helps to identify and address trends in specific areas. The health information team also has developed a documentation due date tracker, to identify upcoming treatment plan reviews. For our monthly performance improvement, the Clinical Director, and Clinical Supervisor will discuss the master treatment plan review in the monthly chart audit committee meetings to ensure compliance. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on two of five applicable detoxification client records reviewed, the facility failed to provide a psychosocial evaluation in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicates biopsychosocial histories occur within 72 hours and the psychosocial summary occur with five days.
Client # 2 was admitted on February 9, 2023 and was still active at the time of the inspection. The psychosocial evaluation had not been completed at the time of the inspection and was due February 14, 2023.
Client # 4 was admitted on February 10, 2023 and was still active at the time of the inspection. The psychosocial evaluation had not been completed at the time of the inspection and was due February 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and the Clinical Director will review the daily census with the Clinical Assessors in morning shift report to determine which clients are due each day to ensure the psychosocial evaluations are being complete within the timeframe. The health information manager sends out a health information discrepancy report bi-weekly that monitors discrepancies in timeframes directly related to the psychosocial evaluations. This tool helps to identify and address trends in specific areas, and to focus training and development of staff. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on three of seven residential applicable client records reviewed, the facility failed to provide documentation assuring that counseling services are provided according to the individual treatment and rehabilitation plan.
Client # 1 was admitted on January 26, 2023 and was still active at the time of the inspection. An individual treatment and rehabilitation plan developed on January 29, 2023 indicated one individual counseling session weekly and six groups daily. After review of the client record of service and progress notes, no groups were documented on February 9, 13, and 16, 2023.
Client # 3 was admitted on January 23, 2023 and was still active at the time of the inspection. An individual treatment and rehabilitation plan developed on February 2, 2023 indicated one individual counseling session weekly and six groups daily. After review of the client record of service and progress notes, no groups were documented on February 13, 2023 and no individual the week of February 5-11, 2023.
Client # 4 was admitted on January 20, 2023 and was still active at the time of the inspection. An individual treatment and rehabilitation plan developed on January 31, 2023 indicated one individual counseling session weekly and six groups daily. After review of the client record of service and progress notes, no groups were documented on February 13 and 14, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/20/23 the Clinical Director, Clinical Supervisor, and Compliance Specialist had a meeting to discuss how we can improve the documentation process associated with the progress notes, and individual sessions being completed in accordance with the individual's treatment plan. The health information manager sends out a health information discrepancy report bi-weekly that monitors discrepancies directly related to progress notes, and individual notes. This process is utilized to monitor and address trends and help clinical improve the documentation process. The compliance of progress notes and individual notes will be monitored in the monthly chart audit committee meetings to sustain compliance. |