This report is a result of an on-site licensure renewal inspection conducted on April 13-15, 17, and 20-22, 2026, 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. 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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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of five applicable records.
Client #5 was admitted to the outpatient level of care on October 7, 2025, and was still active at the time of the inspection. A treatment plan update was completed on February 10, 2026, and the next update was due no later than April 10, 2026; however, there were no further updates in the record.
Client #6 was admitted to the outpatient level of care on September 25, 2025, and was still active at the time of the inspection. A treatment plan update was completed on November 24, 2025, and the next update was due no later than January 24, 2026; however, it was completed on February 16, 2026.
Client #7 was admitted to the outpatient level of care on September 24, 2025, and was still active at the time of the inspection. A treatment plan update was completed on December 3, 2025, and the next update was due no later than February3, 2026; however, it was completed on February 16, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Therapists and Clinical staff were re-educated on DDAP documentation requirements, policies and treatment plan timelines on 5/14/26.
To prevent recurrence, the agency has reviewed the implemented a treatment plan tracking tool to monitor due dates and completion status for all clients. Clinical supervisors will review paperwork compliance and clinician caseloads during all scheduled supervision sessions to ensure documentation is completed timely.
Monthly Quality Assurance reviews will be conducted to audit charts for compliance with treatment plan requirements, signatures, and documentation timelines. Any identified deficiencies will be addressed through corrective supervision, additional training, and ongoing monitoring.
The Program Director and Clinical Supervisors will be responsible for ensuring continued compliance with DDAP regulations and will review in supervisions monthly |