INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25,2010 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 September 24, 2010.
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the observation which occurred during the licensing survey, the facility failed to ensure privacy in counseling sessions and conversations.
The findings include:
Two counseling sessions were conducted during the course of the licensing survey on August 25, 2010. The facility failed to ensure client confidentiality during counseling sessions as interactions between the counselor and the clients could be heard by the licensing specialist and other staff members at approximately 2:45 PM.
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Plan of Correction
We have purchased noise makers to put outside each of the offices in Hyde.The maintinance department installed the noise blockers outside each office space. the Project Director verified location of installation.These noise makers have been permanently installed on the outside of each office space. They will be throughout the building. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an onsite inspection, the fire extinguishers had not been inspected annually.
The findings include:
Four fire extinguishers were inspected at the August 25, 2010. There was no documentation that indicated the fires extinguishers had been inspected. An interview with the facility manager and the project director at 2:30 PM, confirmed that the fire extinguishers had not been inspected since August 5, 2009.
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Plan of Correction
New inspection occured of fire extinguishers on 8/26/10. Up to date. Project Director has implemented an annual review of building maintinance and safety reviews. This will be done annually along with the safety enforcer of CCS. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of three client records, the facility failed to document case consultation notes in one of three client records
The findings include:
Three client records were reviewed on August 25, 2010. The facility failed to document a case consultation note on record #9. A conversation with the counselor and the project director confirmed that the facility failed to include case consultation notes in the client record.
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Plan of Correction
we have implemented that the project director will complete case consults in the allotted 60 days of treatment. This will reviewed in chart audits by the project director. |