INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 2025, 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 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(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 eleven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three employees received the minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #4 was hired as medical receptionist on May 1, 2023 and was due to have the communicable disease trainings no later than May 1, 2025. As of the date of the inspection, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training.
Employee #9 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 in the personnel file of the completion of the HIV/AIDS training and the TB/STD training.
Employee #10 was hired as a certified recovery specialist on July 17, 2017, and was due to have the communicable disease trainings no later than July 17, 2019; however, the HIV/AIDS training was not completed until April 4, 2024 and the TB/STD training was not completed as of the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 23, 2024 licensing inspection.
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Plan of Correction
All current PA employees will be trained on the following Communicable Diseases of HIV/AIDS and TB/STD through DDAP directly.
The locations Center Manager will be responsible for ensuring all staff receive the required training by end of Q3 9/30/2025.
All new employees will be trained within their 1st or 2nd year of employment via DDAP directly. The locations Center Manager will be responsible for tracking completing of these trainings in the required timeframe. 6-month audits on required trainings will be conducted by the Learning and Development team. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one out of seven records reviewed.
Client #2 was admitted on July 25, 2024 and was discharged on September 24, 2024.While the client had been released from the outpatient activity, the court system requested information and the facility obtained a release of information from the client on February 11, 2025; however the specific information to be disclosed was not documented on the form prior to disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CleanSlate's Learning and Development team will conduct a training session for all staff on the correct procedures for completing the Release of Information for all patients and a process for ensuring ROI's are placed in the patient chart. The training session be completed on 6/17/2025 by the Learning and Development Team.
Ongoing auditing for correct completion of ROI's will be completed by the programs Center Manager on a 6 month basis to ensure compliance with this regulation. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #3 was admitted on April 23, 2024 and was discharged on September 12, 2024. A comprehensive treatment plan was completed on May 14, 2024, and an update was due no later than July 14, 2024; however, there were no treatment plan updates documented.
Client #6 was admitted on April 20, 2024 and was discharged on September 4, 2024. A comprehensive treatment plan was completed on April 20, 2024, and an update was due no later than June 20, 2024; however, there were no treatment plan updates documented.
Client #7 was admitted on April 30, 2024 and was discharged on March 03, 2025. A comprehensive treatment plan was completed on July 02, 2024, and an update was due no later than September 02, 2024; however, there were no treatment plan updates documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 23, 2024 licensing inspection.
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Plan of Correction
CleanSlate's Behavioral Health Director will complete training with all new incoming counseling staff upon hire to review treatment plan updates being completed every 60 days.
The Behavioral Health Director who oversees counseling staff will be responsible for ensuring completing of training plans every 60 days for all counseling patients.
Ongoing auditing of the counselor's caseload will occur every 6 months to ensure compliance with this regulation. Auditing will take place by the Behavioral Health Director. |