INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1-3, 2023 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill records, the facility failed to maintain a written fire drill records that includes documentation of problems encountered.
Fire drill records were reviewed from April 2022 to March 2023. Fire drills documented from April 2022 through Oct 2022, Dec 2023, February 2023, and March 2023 did not include problems encountered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The form being utilized by the entity contracted to perform fire-drills contained a section for comments with the heading "Tech Notes." When no problems or issues were encountered, no documentation was being entered into this portion of the form.
This form has been revised and this field updated from "Tech Notes" to "Problems Encountered," and has been made a mandatory field. Education occurred with the contracted entity on 4/12/23 that documentation should reflect any issues encountered during the drill, and/or, when no issues are encountered. This implementation was completed for implementation in May, 2023. Fire Drills will be audited by the third week of each month by Outpatient Director to ensure compliance with all aspects of regulatory requirements and request that drills be re-performed and appropriately documented by end of the month in instances where continued deficiencies are identified.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission to the client in seven of seven records.
Neither the handbook nor the documentation the clients sign at intake includes the criteria for admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.91: The SUD Welcome packet provided to all consumers at the time of admission has been revised to include criteria for admission, treatment, completion, and discharge. Welcome packets are provided to all consumers as part of their intake, and written attestation to this effect is obtained during the intake appointment in the "Multi-Consent" documentation. This change will take effect on 5/1/23. Facility Directors and Clinical Supervisors have been made aware of this change, and all active consumers will be provided a copy of the revised SUD Welcome Packet which clearly outlines these criterion. Quality Assurance will, as part of their ongoing monthly quality monitoring, ensure that a valid and signed multi-consent is on-file indicating that consumers received a copy of the revised SUD Welcome Packet. These findings will be reviewed with Regional Managers for follow-up when deficiencies are identified. |