INITIAL COMMENTS
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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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of seven records.
Client #2 was admitted to the outpatient level of care on August 19, 2024, and discharged on February 5, 2025. A treatment plan was completed on September 18, 2024, and an update was due no later than November 18, 2024; however, it was completed on November 20, 2024. The next update was due no later than January 20, 2025; however, it was completed on January 22, 2025.
Client #3 was admitted to the outpatient level of care on August 21, 2024, and discharged on February 27, 2025. A treatment plan was completed on October 1, 2024, and an update was due no later than December 1, 2024; however, it was completed on December 19, 2024. The next update was due no later than February 19, 2025; however, it was completed on February 27, 2025.
Client #6 was admitted to the outpatient level of care on November 25, 2024, and was still active at the time of the inspection. A treatment plan update was completed on February 6, 2025, and the next update was due no later than April 6, 2025; however, it was completed April 14, 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. |
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 a review of client records, the facility failed to document follow-up information in two of four applicable records.
The facility's policy and procedure states follow-up call will be made, and questionnaire will be sent to the client at 30 days, and another one at 6 months.
Client #3 was admitted to the outpatient level of care on August 21, 2024, and discharged on February 27, 2025. A follow-up call was due no later than March 29, 2025; however, it was completed on March 31, 2025.
Client #4 was admitted to the outpatient level of care on September 17, 2024, and discharged on January 8, 2025. A follow-up call was due no later than February 8, 2025; however, it was completed on February 11, 2025.
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. |