INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 5-7, 2022 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of all staff being instructed on the use of the fire extinguisher upon employment.
Employee # 4 was hired as a counselor on January 14, 2022 and was still in this position at the time of the inspection. There was no documentation of fire extinguisher training in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will have employee complete training and this will be documented in the personnel file. In the future, HR will ensure that all fire extinguisher and emergency training is completed during orientation and documentation will be placed in the personnel file. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to provide documentation ensuring all personnel on all shifts are trained to perform assigned tasks during emergencies
Employee # 4 was hired as a counselor on January 14, 2022 and was still in this position at the time of the inspection. There was no documentation of emergency training in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will have employee complete training and this will be documented in the personnel file. In the future, HR will ensure that all fire extinguisher and emergency training is completed during orientation and documentation will be placed in the personnel file. |
709.28 (c) 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.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 3.
Client # 3 was admitted on November 19, 2021 and was still active at the time of the inspection. Authorizations for funding occurred on November 19, 2021 however, an informed and voluntary consent from the client for the disclosure of information to a funding source was not signed by the client until January 11, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained on ROI procedures and timeliness. Clinical Supervisors will be reviewing to ensure correct procedure is being followed. |