INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 28-29, 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, 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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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.
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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 #1 was admitted on December 10, 2024, and discharged on March 7, 2025. A treatment plan was completed on December 20, 2024, and an update was due no later than February 20, 2025. There were no updates in client #1 ' s record.
Client #2 was admitted on October 30, 2024, and discharged on January 31, 2025. A treatment plan was completed on November 7, 2024, and an update was due no later than January 7, 2025; however, it was completed on January 8, 2025.
Client #6 was admitted on January 3, 2025, and was still active the time of inspection. A treatment plan was completed on January 3, 2025, and an update was due no later than March 3, 2025; however, it was completed on March 6, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
An Sud Caseload report was created on 5/7/25. This report shows several areas that are pertinent to the caseload including the due date of the next treatment plan review. The clinical supervisor will Monitor and send the SUD Caseload report to their therapists weekly. The therapist will be responsible for reviewing and completing the treatment plan reviews according to the regulations of at least every 60 days. Clinical Supervisor will review with the therapist during weekly supervisions. This will ensure that the treatment plan reviews are completed withing the 60 day window. |
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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of four applicable records.
The facility's policy and procedure states a follow-up call will be made, and a questionnaire will be sent to the client at 30 days, and another one at 6 months.
Client #1 was admitted on December 10, 2024, and discharged on March 7, 2025. A follow-up call was due no later than April 7, 2025. There was no follow up documented in client #1 ' s record.
Client #2 was admitted on October 30, 2024, and discharged on January 31, 2025. A follow-up call was due no later than March 1, 2025. There was no follow up documented in client #2 ' s record.
Client #4 was admitted on October 30, 2024, and discharged on December 18, 2024. A follow-up call was due no later than January 18, 2025. There was no follow up documented in client #4 ' s record.
These findings were reviewed with the facility staff during the licensing process.
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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. |