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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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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed be limited to 255.5 (b) for a government or funding agency.
Client # 4 was admitted on December 29, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a state community corrections center allowed for the release of "significant medical, social, occupational, and family history records, significant and/or referral contracts, including follow-up referral, records and consultations/conversations within service providers, releases of information forms, record of service, documentation of monitoring of the service plan".
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 with special attention on Government and funding ROI. Clinical Supervisors will be reviewing to ensure correct procedure is being followed. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on two of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 30 days and 60 days by letter.
Client # 5 was admitted on September 1, 2021 and discharged on December 8, 2021. There was no 60 day follow-up information documented in the client record.
Client # 7 was admitted on October 20, 2021 and discharged on December 15, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will send out the policy and staff will review the policy for follow up with consumers following discharge to ensure that consumers are following aftercare plan and/or in need of referral for services. The Clinical Supervisor will ensure that the navigator will follow up with individuals 7days, 30 day and 180 days following discharge. |