INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21-22, 2013 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:
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on August 21, 2013. The fire drills conducted from August 2012-August 2013 were reviewed. The exit route documented as used during the fire drill was the "back" exit for all fire drills conducted.
The Project Director and the Facility Director confirmed the findings.
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Plan of Correction
On August 28, 2013, the Project Director informed all DA staff that they are to utilize alternating exits in the building during all fire drills. The fire drill log will be reviewed quarterly by the Project Director to ensure that all exits are being utilized during drills. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of eight client records.
The findings include:
Eight client records which required documentation of type and frequency of rehabilitation services on the individual treatment and rehabilitation plan were reviewed on August 21-22, 2013. The facility failed to document the frequency of which services were to be provided in client records # 1, 3, 4, and 5.
Client #1 was admitted on 7/31/13. The individual treatment and rehabilitation plan was developed on 8/12/13. The frequency of which Individual Counseling was to be provided to this client was not documented on their treatment plan.
Client #3 was admitted on 5/9/13. The individual treatment and rehabilitation plan was developed on 6/6/13. The frequency of which Individual Counseling was to be provided to this client was not documented on their treatment plan.
Client #4 was admitted on 7/11/13. The individual treatment and rehabilitation plan was developed on 8/15/13. The frequency of which Individual Counseling was to be provided to this client was not documented on their treatment plan.
Client #5 was admitted on 6/19/13. The individual treatment and rehabilitation plan was developed on 8/19/13. The frequency of which Individual Counseling was to be provided to this client was not documented on their treatment plan.
The Project Director and Facility Director confirmed the findings.
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Plan of Correction
The IT department updated the treatment plan to include the frequency of the service being provided on August 21, 2013. The Facility Director will monitor weekly all documentation to ensure all components are completed as required. The treatment plans from July 2013 to August 2013 have been reviewed and updated to reflect the frequency of service required and treatment plans have been amended to reflect this. All treatment plans were updated by August 31, 2013 by the indidual therapist. |