INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 24 & 25, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child Services, 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 and a plan of correction is due on October 26, 2007.
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Plan of Correction
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based upon review of the 2006 - 2007 annual report on 9/24/2007, it was determined that the facility failed to provide a financial statement that documented income and expenses. The annual report did not include facility expenses for any of the departments, nor the facility as a whole. The annual report for the fiscal year August 2006 - July 2007 did not include revenues for the drug and alcohol treatment component of the project.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based upon review of the 2006 - 2007 annual report on 9/24/2007, it was determined that the facility failed to disclose the names of officers and directors where required. The annual report did not list the names of the officers and directors of the board.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based upon a review of the facility's policies and procedures manual on 9/24/2007, it was determined that the facility failed to provide a written procedure which complied with the client confidentiality requirements at 4 Pa. Code subsection 255.5. The policy and procedures allowed for a Duty to Warn that was not specific to reporting child abuse or suspected child abuse as outlined in the federal regulations at 42 CFR Part 2, Subpart B, subsection 2.12(c); and it failed to restrict information released to judges, probation and parole officers to that which is permissible under the limitations imposed at 4 Pa Code subsection 255.5(b), and at 42 CFR Part II, Subpart E, subsection 2.63.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon review of consent to release information forms in client records on 9/25/2007, it was determined that the facility failed to provide clients with an informed consent in 4 of 4 client records reviewed. Client records # 1, 3 & 4 contained consents to release information which included the verbiage "recommendations", in the information to be released without identifying specifically what information "recommendations" included. The consent in client record #1 dated 8/29/07 was to the parole officer, the consent in client record #3 dated 7/14/06 was to the Jefferson County Adult Probation Office. The consent in client record #4 was to the Jefferson County Adult Probation Office.
Client records #1 & 2 contained consents to release information that identified the information to be released as: information to meet the requirements of the SCA for funding client's treatment. This does not constitute an informed consent.
Client records #1 & 2 contained consents to release information to the Department of Public Welfare that identified the information to be released as: information to ensure proper funding for treatment. The forms in client record #1 were dated 6/25/06 & 8/29/07. The forms in client record #2 were dated 5/10/07.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based upon review of consent to release information forms in client records on 9/25/2007, the facility failed to identify the specific information to be disclosed in 4 of 4 records reviewed. Client records # 1, 3 & 4 contained consents to release information which included the verbiage "recommendations" in the information to be released without identifying specifically what information "recommendations" included. The consent in client record #1 dated 8/29/07 was to the parole officer, the consent in client record #3 dated 7/14/06 was to the Jefferson County Adult Probation Office. The consent in client record #4 was to the Jefferson County Adult Probation Office. This does not identify the specific information to be released.
Client records #1 & 2 contained consents to release information that identified the information to be released as: information to meet the requirements of the SCA for funding client's treatment. This does not identify the specific information that will be released.
Client records #1 & 2 contained consents to release information to the Department of Public Welfare that identified the information to be released as: information to ensure proper funding for treatment. The forms in client record #1 were dated 6/25/06 & 8/29/07. The form in client record #2 was dated 5/10/07. This does not identify the specific information to be released.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based upon review of client records on 9/25/2007, it was determined that the facility failed to provide documentation of a the client's physical exam in 1 of 1 records requiring a physical exam. Client record #4 contained a copy of the client's consent to allow the physician to release the physical examination to the facility (dated 4/12/07), however the physical examination document was not in the client record.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon review of client treatment plan updates on 9/25/2007, it was determined that the facility failed to provide a detailed report on the client's progress relative to the treatment goals set in previous treatment plans in 4 of 4 client records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based upon review of client records on 9/25/2007, it was determined that the facility failed to identify support services and/or goals with specific time frames in two of two records reviewed. Client records #3 & 4 lacked goals with specific time frames for completion. Client record #3 did not list any support services in the aftercare plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based upon client discharge summaries reviewed on 9/25/2007, it was determined that the facility failed to document that they were completed within 7 days of the discharge date. Client records #3 & 4 contained discharge summaries that were not dated when completed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon client records reviewed on 9/25/2007, it was determined that the facility failed to document follow up attempts in 2 of 2 client records reviewed. Client records #3 & 4 lacked documentation to verify that the facility had conducted a follow up on clients in accordance with the facility's policy and procedure.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |