INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2022 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. - Scranton North 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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704.11(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 facility's administrative records, the facility failed to complete an assessment of staff training needs for the training year of 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate shall ensure a comprehensive Staff Development Program is developed for Personnel including policies & procedures for our program indicating responsibility & timeframes for completion of an assessment of Staff training needs.
In the future, an assessment of Staff training needs shall be completed for the year & findings shall be made available for review during the licensure inspection process.
Timeline ? the need to have a comprehensive Staff Development Program shall be reviewed with the Human Resources/Learning & Development department at an upcoming implementation meeting in April 2022 in response & follow-up to the Inspection that identified this deficiency on 2/15/2022. The Manager of Learning & Development shall ensure that an assessment of Staff training needs is completed on an ongoing-basis for each training year & made available for verification including applicable policies & procedures which will be updated accordingly.
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's administrative records, the facility failed to develop an overall plan addressing staff training needs for the year of 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate shall ensure a comprehensive Staff Development Program is developed for Personnel including policies & procedures for our program indicating responsibility & timeframes for completion of an overall plan addressing Staff training needs for the year.
In the future, a developed overall plan for addressing Staff training needs shall be completed for the year & findings shall be made available for review during the licensure inspection process.
Timeline ? the need to have a comprehensive Staff Development Program shall be reviewed with the Human Resources/Learning & Development department at an upcoming implementation meeting in April 2022 in response & follow-up to the Inspection that identified this deficiency on 2/15/2022. The Manager of Learning & Development shall ensure that an overall plan for addressing Staff training needs is developed, completed on an ongoing-basis for each training year & made available for verification including applicable policies & procedures.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's administrative records, the facility failed to complete an annual evaluation of the overall training plan for the year of 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate shall ensure a comprehensive Staff Development Program is developed for Personnel including policies & procedures for our program indicating responsibility & timeframes for completion of an annual evaluation of our overall training plan.
In the future, an annual evaluation of the overall training plan for the year addressing Staff training needs shall be completed & findings shall be made available for review during the licensure inspection process.
Timeline ? the need to have a comprehensive Staff Development Program shall be reviewed with the Human Resources/Learning & Development department at an upcoming meeting in April 2022 in response & follow-up to the Inspection that identified this deficiency on 2/15/2022. The Manager of Learning & Development shall ensure that an annual evaluation of our overall training plan for addressing Staff training needs is completed on an ongoing-basis for each training year & made available for verification including applicable policies & procedures.
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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 a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records the facility failed to document a written individual training plan for each employee for two out of two staff.
Staff #1 was hired as the Project Director on February 4, 2022, and did not have a documented individual training plan.
Staff #2 was hired as the Facility Director on February 22, 2021, and did not have a documented individual training plan.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate shall ensure that a written Individual Training Plan be developed for each Employee appropriate to that Employee's skill level annually with input from both the Employee & the Supervisor.
In the future, the Staffing Requirements Facility Summary Report (SRFSR) & personnel records documenting a written Individual Training Plan for both the Project Director & the Facility Director shall be made available for review during the licensure inspection process.
Timeline ? the need to have a written Individual Training Plan for both the Project Director & the Facility Director shall be reviewed with the Human Resources/Learning & Development department at an upcoming meeting in April 2022 in response & follow-up to the Inspection that identified this deficiency on 2/15/2022. The Manager of Learning & Development shall ensure that the written Individual Training Plan is completed on an ongoing-basis & made available for verification via our Learning Management Software (LMS).
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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 a review of the facility's fire drill log from May 2021 through January 2022, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate shall ensure that the facility sets off a fire alarm or smoke detector during each fire drill.
In the future, the facility's documented fire drill log reflecting that the facility set off a fire alarm or smoke detector during each fire drill shall be made available for review during the licensure inspection process.
Timeline ? the need for simulating the sound of a fire alarm/smoke detector was discussed at a Center Staff team meeting following the Inspection that identified this deficiency on 2/15/2022. The monthly fire drill that was conducted subsequently on 2/25/2022 at the Center location for the month of February included documentation that the sound of a fire alarm was engaged & utilized to initiate the drill. This will be done consistently in the future. Compliance with completion shall be the responsibility of operational leadership (Center Manager, Center Supervisor or designee). They shall submit monthly fire drill logs for monitoring & oversight as part of our Health & Safety Program. Additionally, monthly fire drill log forms shall be updated/revised to ensure the simulation of the sound of a fire alarm/smoke detector to be verified & documented each & every drill.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the facility's personnel records, the facility failed to ensure that one out of one staff member had a written annual performance completed.
Staff #2 was hired on February 2, 2021 as a facility director and should have had an annual work performance completed no later than February 2, 2022.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate shall ensure that Personnel Records include annual written individual Staff performance evaluations reviewed & signed by the Employee.
In the future, the Facility Director's written annual work performance shall be completed & made available for review during the licensure inspection process.
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