This report is a result of an on-site licensure renewal inspection conducted on April 28-29, 2025, 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:
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Plan of Correction
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in five of seven records.
Client #1 was admitted to the outpatient level of care on August 2, 2024, and discharged on March 31, 2025. A treatment plan update was completed on October 7, 2024, and the next update was due no later than December 7, 2024, 2024; however, it was completed on December 9, 2024. The next update was due no later than February 9, 2025; however, it was completed on March 17, 2025.
Client #2 was admitted to the outpatient level of care on September 18, 2024, and discharged on February 19, 2025. A treatment plan was completed on September 30, 2024, and an update was due no later than November 30, 2024. There were no further updates in client #2 ' s record.
Client #3 was admitted to the outpatient level of care on November 20, 2024, and discharged on April 3, 2025. A treatment plan was completed on December 2, 2024, and the update was due no later than February 2, 2025; however, it was completed on February 13, 2025.
Client #4 was admitted to the outpatient level of care on December 9, 2024, and was still active at the time of the inspection. A treatment plan was completed on January 2, 2025, and the update was due no later than March 2, 2025. There were no further updates in client #4 ' s record.
Client #5 was admitted to the outpatient level of care on October 7, 2024, and was still active at the time of the inspection. A treatment plan update was completed on December 3, 2024, and the next update was due no later than February 3, 2025; however, it was completed February 7, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
An Sud Caseload report was created on 5/7/25. This report shows several areas that are pertinent to the caseload including the due date of the next treatment plan review. The clinical supervisor will Monitor and send the SUD Caseload report to their therapists weekly. The therapist will be responsible for reviewing and completing the treatment plan reviews according to the regulations of at least every 60 days. Clinical Supervisor will review with the therapist during weekly supervisions. This will ensure that the treatment plan reviews are completed withing the 60 day window. |
Observations
Based on a review of client records, the facility failed to document follow-up information in two of two applicable records.
The facility's policy and procedure states a follow-up call will be made, and a questionnaire will be sent to the client at 30 days, and another one at 6 months.
Client #2 was admitted to the outpatient level of care on September 18, 2024, and discharged on February 19, 2025. A follow-up call was due no later than March 19, 2025. There was no follow-up documented in client #2 ' s record.
Client #4 was admitted to the outpatient level of care on December 9, 2024, and discharged on March 17, 2025. A follow-up call was due no later than April 17, 202.5. There was no follow-up documented in client #4 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor educated Navigators (Care coordinators) on 5/8/25 on completing follow up calls with discharged clients at 30 days and 6 months. All navigators will follow the same process of documenting in a discharge contact note that a client is being discharged. Within the contact note the dates of when the follow ? up calls need to occur will be noted. The navigators will then run a report weekly to ensure that all discharge follow ups occur. If the date of the follow ups fall on a weekend or holiday, the follow up call should occur on the last business day before the weekend or holiday. Clinical Supervisor will also run the report to monitor that all follow ups are completed in a timely manner. |