INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2024, 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 staff development program, the facility failed to complete an assessment of staff training needs for the current training year, January 31, 2024 through December 31, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that an assessment of Staff training needs is completed for each training year as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for completing an annual assessment of Staff training needs in collaboration with the Project Director & Organizational Leadership.
The annual Staff training needs assessment for training year 2024 will be completed by the end of Q2 2024.
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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 staff development program, the facility failed to develop an overall plan for addressing staff training needs for the current training year, January 31, 2024 through December 31, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that an overall Staff training plan is completed for each training year as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for establishing an annual overall Staff training plan in collaboration with the Project Director & Organizational Leadership.
The annual overall Staff training plan addressing assessed Staff training needs for training year 2024 will be completed by the end of Q2 2024.
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility's staff development program and employee training records, the facility failed to develop a mechanism to collect feedback on completed trainings.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that a mechanism to collect feedback on completed training is established & implemented as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for establishing & implementing the completed training feedback collection mechanism in collaboration with the Project Director & Organizational Leadership.
The feedback collection mechanism for completed training will be established & implemented by the end of Q2 2024.
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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 staff development program, the facility failed to failed to complete an annual evaluation of the overall training plan for training year January 31, 2023 through December 31, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training & education to ensure that an annual evaluation of the overall Staff training plan is conducted for each training year as part of CleanSlate's comprehensive Staff Development Program.
The CleanSlate Learning & Development Department will be responsible for conducting an annual evaluation of the overall Staff training plan in collaboration with the Project Director & Organizational Leadership.
The annual evaluation of the overall Staff training plan for training year 2024 will be completed by the end of Q4 2024.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that facility staff received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a certified recovery specialist on May 2, 2022 and was due to have the communicable disease trainings no later than May 2, 2024. As of the date of the inspection, there was no documentation of the completion of the HIV/AIDS training and the TB/STD training.
Employee #4 was hired as a a certified recovery specialist on July 17, 2017, and was due to have the communicable disease trainings no later than July 17, 2019. As of the date of the inspection, there was no documentation of the completion of the HIV/AIDS training and the TB/STD training.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will revise & update its Learning & Development policies & procedures for Personnel training and education to ensure that all new employees will be required to complete the Communicable Disease trainings. Non-Clinical staff within their 1st 2 years of employment and Clinical staff within their 1st year of employment.
The CleanSlate Learning &Development Department team along with the Project Director and Operational Leadership will be responsible for tracking the completion of these required trainings on a yearly basis.
All new staff will have the Communicable Disease trainings listed on their Annual Training plan, completed by the end of Q4 2024.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facilities policy and procedure manual and interviews with the facility staff, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Policy & Procedure Development & Implementation include documentation of the Project Director's annual preparation, review, update & signature of the Project's policies & procedures.
The CleanSlate Project Director will be responsible for ensuring the documented annual completion for preparation, review, update & signature of the Project's policies & procedures in collaboration with Organizational Leadership.
The documented annual completion for preparation, review, update & signature of the Project's policies & procedures for 2024 will be completed by the end of Q2 2024.
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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 the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures of all the required client rights, including 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 on treatment.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: 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. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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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 the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures to include documentation of all the required client rights, including 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 in four out of seven records. The policy does not include color and marital status.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: 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. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures to inform the client of all their rights. The client rights form given to the client did not identify that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to appeal a decision limiting access to their records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate will ensure its policies & procedures for Patient rights include the following right: Clients have the right to appeal a decision limiting access to their records to the director. This right will also be included in the CleanSlate Patient Handbook, displayed in each CleanSlate Center location & notification shall be documented for each Patient by signature of an acknowledgement of receipt form.
CleanSlate Operational Leadership will be responsible for ensuring that Patient rights are provided to all Patients & documented written acknowledgement that they have been notified of their rights is received from all Patients in collaboration with the Project Director & Organizational Leadership.
All established CleanSlate Patients shall be provided with a copy of their rights & be requested to sign an acknowledgement of receipt form as written documentation that they have been notified of their rights. This process shall be completed by the end of Q2 2024. All Patients will receive notification of their rights & be requested to sign an acknowledgement of receipt form upon intake into treatment moving-forward.
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