This report is a result of an on-site licensure renewal inspection conducted on April 14-16, 2025, 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:
|
Plan of Correction
|
Observations
Based on a review of client records, the facility failed to document follow-up information in three of three applicable records.
The facility's policy and procedure manual states follow-up call will be made, and questionnaire will be sent to the client at 30 days, and another one at 6 months.
Client #2 was admitted on November 6, 2024, and discharged on January 21, 2025. A follow-up call was due no later than February 25, 2025. There was no follow-up in client #2 ' s record.
Client #3 was admitted on December 10, 2024, and discharged on February 18, 2025. A follow-up call was due no later than March 20, 2025; however, it was completed on April 4, 2025.
Client #4 was admitted on January 16, 2025, and discharged on February 21, 2025. A follow-up call was due no later than March 24, 2025; however, it was completed on April 4, 2025.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor educated Navigators (Care coordinators) on 5/8/25 on completing follow up calls with discharged clients at 30 days and 6 months. All navigators will follow the same process of documenting in a discharge contact note that a client is being discharged. Within the contact note the dates of when the follow ? up calls need to occur will be noted. The navigators will then run a report weekly to ensure that all discharge follow ups occur. If the date of the follow ups fall on a weekend or holiday, the follow up call should occur on the last business day before the weekend or holiday. Clinical Supervisor will also run the report to monitor that all follow ups are completed in a timely manner. |