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, 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
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Observations Based on a review of client records, the facility failed to document follow-up information in three of four applicable records.
The facility's policy and procedures state a follow-up call will be made, and questionnaire will be sent to the client within 30 days, and another one at 6 months.
Client #2 was admitted to the outpatient level of care on September 12, 2025, and discharged on January 6, 2026. A follow-up call was due no later than February 6, 2026; however, there was no follow-up documented in the record.
Client #3 was admitted to the outpatient level of care on July 14, 2025, and discharged on October 2, 2025. A follow-up call was due no later than November 2, 2025; however, there was no follow-up documented in the record.
Client #4 was admitted to the outpatient level of care on September 11, 2025, and discharged on December 15, 2025. A follow-up call was due no later than January 15, 2026; however, there was no follow-up documented in the record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the April 28-29, 2025, licensing inspection.
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Plan of Correction Director spoke with staff 0n 5/12/26 regarding follow up calls and provided training on calculation of dates for follow-up calls that included accounting for longer months with 31 days and shorter months with fewer than 30 days in order to ensure that the dates for follow-up calls were calculated correctly. Staff responsible for the follow-up calls were also provided an excel spreadsheet that calculates the date accurately. Staff were also re-educated on completing follow-up calls earlier when the date falls on a weekend or holiday.
The Lead Navigator and Clinical Supervisors will monitor compliance with follow-up call completion and date calculations on an ongoing basis through regular chart reviews and monthly supervisions. In addition, the SUD Director will conduct monthly monitoring to ensure continued compliance with DDAP requirements and implementation of corrective actions. |