This report is a result of an on-site licensure renewal inspection conducted on April 13-15, 17, and 20-22, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child Services, Inc. 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: |
Plan of Correction
|
Observations Based on a review of client records, the facility failed to document treatment plan updates every 60 days in four of seven records.
Client #2 was admitted on October 6, 2025, and discharged on April 6, 2026. A treatment plan update was completed on November 26, 2025, and the next update was due no later than January 26, 2026; however, it was completed on February 5, 2026. The next update was due no later than April 5, 2026; however, it was completed on April 6, 2026.
Client #4 was admitted on October 16, 2025, and was still active at the time of the inspection. A treatment plan update was completed on January 13, 2026, and the next update was due no later than March 13, 2026; however, it was completed on March 26, 2026.
Client #5 was admitted on October 23, 2025, and was still active at the time of the inspection. A treatment plan update was completed on November 17, 2025, and the next update was due no later than January 17, 2026; however, it was completed on January 23, 2026. The next update was due no later than March 23, 2026; however, it was completed on March 25, 2026.
Client #7 was admitted on August 21, 2025, and was still active at the time of the inspection. A treatment plan update was completed on October 30, 2025, and the next update was due no later than December 20, 2025; however, it was completed on January 13, 2026. The next update was due no later than March 13, 2026; however, it was completed on March 26, 2026.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the April 14-16, 2025, licensing inspection.
|
Plan of Correction Therapists and Clinical staff were re-educated on DDAP documentation requirements, policies and treatment plan timelines on 5/14/26.
To prevent recurrence, the agency has reviewed the implemented a treatment plan tracking tool to monitor due dates and completion status for all clients. Clinical supervisors will review paperwork compliance and clinician caseloads during all scheduled supervision sessions to ensure documentation is completed timely.
Monthly Quality Assurance reviews will be conducted to audit charts for compliance with treatment plan requirements, signatures, and documentation timelines. Any identified deficiencies will be addressed through corrective supervision, additional training, and ongoing monitoring.
The Program Director and Clinical Supervisors will be responsible for ensuring continued compliance with DDAP regulations and will review in supervisions monthly.
|