INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1-3, 2023 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 Child Services Inc dba 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 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill records, the facility failed to maintain a written fire drill records that includes documentation whether the fire alarm or smoke detector was operative.
Fire drill records were reviewed from April 2022 to March 2023. Fire drills documented from April 2022 through August 2022 did not include whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative form did not contain a section to indicate whether or not the fire alarm and/or smoke detector were operative. This service has since been contracted out to an entity responsible for randomly conducting monthly fire drills, and who are assessing functionality of the fire alarm and smoke detectors. Education occurred with the contracted entity on 4/12/23 regarding the need to ensure this is consistently monitored and findings documented. Fire Drills will be audited by the third week of each month by Outpatient Director to ensure compliance with all aspects of regulatory requirements and request that drills be re-performed and appropriately documented by end of the month in instances where continued deficiencies are identified. This monitoring will begin in May. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill records, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Fire drill records were reviewed from April 2022 to March 2023. Fire alarms and smoke detectors were not set off for fire drills documented from April 2022 through August 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative form did not contain a section to indicate whether or not the fire alarm and/or smoke detector were operative. This service has since been contracted out to an entity responsible for randomly conducting monthly fire drills, and who are assessing functionality of the fire alarm and smoke detectors. Education occurred with the contracted entity on 4/12/23 regarding the need to ensure this is consistently monitored and findings documented. Fire Drills will be audited by the third week of each month by Outpatient Director to ensure compliance with all aspects of regulatory requirements and request that drills be re-performed and appropriately documented by end of the month in instances where continued deficiencies are identified. Departmental Assistants and those responsible for completing fire drills were provided education on May 8, 2023, regarding these expectations. Should monitoring determine that the fire alarm and/or smoke detector were not set off, another drill will occur so that all regulatory requirements can be satisfied. This monitoring will begin in May. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission to the client in seven of seven records.
Neither the handbook nor the documentation the clients sign at intake includes the criteria for admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The SUD Welcome packet provided to all consumers at the time of admission has been revised to include criteria for admission, treatment, completion, and discharge. Welcome packets are provided to all consumers as part of their intake, and written attestation to this effect is obtained during the intake appointment in the "Multi-Consent" documentation. This change will take effect on 5/1/23. Facility Directors and Clinical Supervisors have been made aware of this change, and all active consumers will be provided a copy of the revised SUD Welcome Packet which clearly outlines these criterion. Quality Assurance will, as part of their ongoing monthly quality monitoring, ensure that a valid and signed multi-consent is on-file indicating that consumers received a copy of the revised SUD Welcome Packet. These findings will be reviewed with Regional Managers for follow-up when deficiencies are identified. |
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 update treatment plans within 60 days in two of five records reviewed.
Client #1 was admitted on October 11, 2022 and discharged on December 20, 2022. The treatment plan update was due on November 10, 2022 and was never completed.
Client #3 was admitted on November 15, 2022 and was still an active client at the time of inspection. The treatment plan update was due on January 16, 2023 but not completed until January 24, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with our Quality Assurance Department and Regional Management Staff on 5/3/2023. Findings will be discussed with all staff during monthly department meeting on 6/5/2023. Quality Assurance will review records from all staff and sites and assess for timeliness of treatment plans. Findings will be presented to Director of OP and Regional Management staff as they are compiled. Regional Managers will notify Clinical Supervisors assigned to the staff person in each instance where a treatment plan is not completed in a timely fashion so additional education and training can be provided. To aide in documentation prioritization, Clinical Supervisors will also use facility's EHR reporting functionality to provide staff with a list of documentation due each Monday. |