INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2-4, 2022 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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 provide group counseling in a room that could not be seen or heard outside the counseling room. The group counseling room door was open by several inches and the full-length window in the door was unobstructed, allowing visual access. These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
On 3/4/22 brand new blinds were installed to ensure privacy of the group room, there is no longer visual access. The Clinical Director and Compliance Support Specialist met with the Primary Counselor that was running a group with the door partially opened and discussed the importance of confidentiality. Due to the counselors concern of the room being too hot, the maintenance team was made aware and have been monitoring the temperature of Group room 1 to ensure that the heating condition is suitable for the comfort of the participants and the door to remain closed while in session. The Compliance Support Specialist has been doing weekly walk through of the Clinical Building while group and individual sessions are in process to ensure all doors are closed and blinds are shut. For our monthly performance improvement meeting we have added a spot check to out Operations Audit. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off of the floor in the refrigerator and freezer of the food preparation area. There was a bag of onions stored on the refrigerator floor and two boxes stored on the floor of the freezer. These findings were reviewed with the facility during the inspection process.
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Plan of Correction
On 3/4/22 the boxes were immediately removed from the floor in the refrigerator and the freezer area and placed properly on the shelves. The Head Chef and the kitchen staff were made aware of the licensing findings. The Head Chef will monitor and prevent any further deficiencies. The Compliance Support Specialist has been doing weekly walk through to ensure that there are no boxes/bags containing food items are being stored on the floor in the freezer/ refrigerator. For our monthly performance improvement meeting we have added a spot check to our Operations Audit. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information in fourteen out of fourteen records reviewed, as there were forms that were missing required information. Client #1 was admitted on February 4, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 4, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #2 was admitted on February 4, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 4, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #3 was admitted on February 14, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 14, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #4 was admitted on January 26, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on January 26, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #5 was admitted on December 15, 2021 and was discharged on February 14, 2022. There was a consent to release form, signed and dated on December 15, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #6 was admitted on October 31, 2021 and was discharged on December 1, 2021. There was a consent to release form, signed and dated on October 31, 2021 to a laboratory, but the consent form did not include a dated signature of witness. Client #7 was admitted on September 21, 2021 and was discharged on October 28, 2021. There was a consent to release form, signed and dated on September 23, 2021 to a laboratory, but the consent form did not include a dated signature of witness. Client #8 was admitted on February 27, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 27, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #9 was admitted on February 27, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 27, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #10 was admitted on February 28, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 28, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #11 was admitted on February 28, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 28, 2022 to a laboratory, but the consent form did not include a dated signature of witness. Client #12 was admitted on October 26, 2021 and was discharge on October 28, 2021. There was a consent to release form, signed and dated on October 26, 2021 to a laboratory, but the consent form did not include a dated signature of witness. Client #13 was admitted on October 12, 2021 and was still discharged on October 14, 2021. There was a consent to release form, signed and dated on October 12, 2021 to a laboratory, but the consent form did not include a dated signature of witness. Client #14 was admitted on February 16, 2022 and was still discharged on February 18, 2022. There was a consent to release form, signed and dated on February 16, 2022 to a laboratory, but the consent form did not include a dated signature of witness. These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The Health Information Officer altered the backend settings of the electronic medical record on 4/11/22 to require a witness signature on all client consents. The intake coordinator will be responsible for signing as a witness on all client admission consents. If documents are unsigned, they will appear in the closed chart report, which the performance improvement committee reviews monthly. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information in fourteen out of fourteen records reviewed, as there were forms that were missing required information. Client #1 was admitted on February 4, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 4, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #2 was admitted on February 4, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 4, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #3 was admitted on February 14, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 14, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #4 was admitted on January 26, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on January 26, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #5 was admitted on December 15, 2021 and was discharged on February 14, 2022. There was a consent to release form, signed and dated on December 15, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #6 was admitted on October 31, 2021 and was discharged on December 1, 2021. There was a consent to release form, signed and dated on October 31, 2021 to treatment facilities, but the consent form did not include an expiration date. Client #7 was admitted on September 21, 2021 and was discharged on October 28, 2021. There was a consent to release form, signed and dated on September 23, 2021 to treatment facilities, but the consent form did not include an expiration date. Client #8 was admitted on February 27, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 27, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #9 was admitted on February 27, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 27, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #10 was admitted on February 28, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 28, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #11 was admitted on February 28, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 28, 2022 to treatment facilities, but the consent form did not include an expiration date. Client #12 was admitted on October 26, 2021 and was discharge on October 28, 2021. There was a consent to release form, signed and dated on October 26, 2021 to treatment facilities, but the consent form did not include an expiration date. Client #13 was admitted on October 12, 2021 and was still discharged on October 14, 2021. There was a consent to release form, signed and dated on October 12, 2021 to treatment facilities, but the consent form did not include an expiration date. Client #14 was admitted on February 16, 2022 and was still discharged on February 18, 2022. There was a consent to release form, signed and dated on February 16, 2022 to treatment facilities, but the consent form did not include an expiration date. These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
All consents that were incorrectly populating without expiration dates have been updated to expire one year from the date of the signature. The Health Information Officer completed this change on 4/11/2022. The performance improvement committee will review this altered documentation every quarter to ensure the changes remain in effect. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information in one out of fourteen records reviewed, as there was a form that was missing information. Client #9 was admitted on February 27, 2022 and was still active at the time of the inspection. There was a consent to release form, signed and dated on February 28, 2022 to an employer, but the consent did not include documentation that the client was offered a copy of the consent. This finding was reviewed with facility staff during the inspection process.
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Plan of Correction
On 3/7/22 the Clinical Director, Intake Supervisor, and Compliance Support Specialist had a meeting to discuss how we can improve the documentation process associated with consents and offering each client the opportunity to have a copy of the consents that they are signing. The supervisor of each department will be retrained for best practice regarding the process and protocol of Client consents and conduct random spot checks on the consents to ensure adherence. Moving forward Clinical staff will audit intake documentation to ensure that all clients are offered a copy of their consent forms. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of one applicable record reviewed. Client #5 was admitted on December 15, 2021 and was discharged on February 14, 2022. A master treatment plan was completed on December 19, 2021 and the treatment plan update was due no later than January 19, 2021; however, there was no treatment plan update documented in the record at the time of the inspection. This finding was reviewed with facility staff during the inspection process.
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Plan of Correction
On 3/7/2022 the Clinical Director and Compliance Support Specialist met with the Primary Counselor to discuss the importance and purpose of the treatment plan update that must be complete every 30 days. Clinical Director, Clinical Supervisor, and Compliance Support Specialist will monitor the census for upcoming clients reaching the 30-day mark to prevent the treatment plan reviews from being overlooked. Treatment plan review compliance will be discussed in the monthly chart audit committee meeting. |