INITIAL COMMENTS
|
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, 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:
|
Plan of Correction
|
709.92(a) 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:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan in three of seven applicable records.
The facility's policy and procedures state that the comprehensive treatment plan must be completed within 14 days.
Client #1 was admitted to the outpatient level of care on July 14, 2025, and discharged on November 24, 2025. A comprehensive treatment plan was due no later than July 28, 2025; however, it was completed August 14, 2025.
Client #2 was admitted to the outpatient level of care on December 1, 2025, and discharged on March 11, 2026. A comprehensive treatment plan was due no later than December 15, 2025; however, it was completed December 23, 2025.
Client #7 was admitted to the outpatient level of care on November 21, 2025, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than December 1, 2025; however, it was completed until December 19, 2025.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The agency has implemented corrective action to ensure compliance with regulation 709.92 regarding timely treatment planning for initial treatment plans to be developed with the client. Effective 6/1/2026, an initial treatment plan will be completed and reviewed with the client on the same date as the initial assessment, if possible, in the event this is not possible, the initial treatment plan will be completed with the client at the client's first session.
Clinical staff have been educated on the revised procedure and documentation expectations on 5/14/26. Clinical supervisors will monitor compliance through ongoing supervision, paperwork review, and monthly chart audits conducted by Quality Assurance. Any deficiencies identified will be addressed immediately through corrective supervision and additional staff training.
The Program Director and Clinical Supervisors will be responsible for ensuring ongoing compliance with this regulation.
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in five of seven records.
Client #1 was admitted to the outpatient level of care on July 14, 2025, and discharged on November 24, 2025. A treatment plan was completed on August 14, 2025, and an
update was due no later than October 14, 2025; however, it was completed on October 24, 2025.
Client #2 was admitted to the outpatient level of care on December 1, 2025, and discharged on March 11, 2026. A treatment plan was completed on December 23, 2025, and an
update was due no later than February 23, 2026; however, there were no updates in the record.
Client #4 was admitted to the outpatient level of care on October 7, 2025, and discharged on February 6, 2026. A treatment plan was completed on October 16, 2025, and an
update was due no later than December 16, 2025; however, it was completed on January 9, 2026.
Client #5 was admitted to the outpatient level of care on November 26, 2025, and was still active at the time of the inspection. A treatment plan was completed on December 3, 2025, and an update was due no later than February 3, 2026; however, it was completed on February 5, 2026.
Client #7 was admitted to the outpatient level of care on November 21, 2025, and was still active at the time of the inspection. A treatment plan was completed on December 19, 2025, and an update was due no later than February 19, 2026; however, it was completed on February 20, 2026.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the April 28-29, 2025, licensing inspection.
|
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.
|
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.
|
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 procedures state a follow-up call will be made, and questionnaire will be sent to the client within 30 days, and another one at 6 months.
Client #1 was admitted to the outpatient level of care on July 14, 2025, and discharged on November 24, 2025. A follow-up call was due no later than December 24, 2025; however,
it was completed on December 29, 2025.
Client #4 was admitted to the outpatient level of care on October 7, 2025, and discharged on February 6, 2026. A follow-up call was due no later than March 6, 2026; however,
it was completed on March 12, 2026.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the April 28-29, 2025, licensing inspection.
|
Plan of Correction
Director spoke with staff 0n 5/12/26 regarding follow up calls and provided training on calculation of dates for follow-up calls that included accounting for longer months with 31 days and shorter months with fewer than 30 days in order to ensure that the dates for follow-up calls were calculated correctly. Staff responsible for the follow-up calls were also provided an excel spreadsheet that calculates the date accurately. Staff were also re-educated on completing follow-up calls earlier when the date falls on a weekend or holiday.
The Lead Navigator and Clinical Supervisors will monitor compliance with follow-up call completion and date calculations on an ongoing basis through regular chart reviews and monthly supervisions. In addition, the SUD Director will conduct monthly monitoring to ensure continued compliance with DDAP requirements and implementation of corrective actions. |