INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Outside In Pathway to Recovery Outpatient Services 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level, and developed annually with input from both the employee and the supervisor for employee # 1.
Employee # 1 was hired as the project director/facility director on May 6, 2021 and was still in this position at the time of the inspection. Employee # 1 did not have a training plan documented in the employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Operations Officer and the Project Director will meet and establish a training plan for the Project Director by April 29, 2023. The Human Resources Manager will ensure that a completed training plan is submitted with the Project Director's annual performance evaluation by the annual due date. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee # 5 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a support staff on February 6, 2020 and promoted to a counselor assistant on November 17, 2022 and was still in this position at the time of the inspection. Employee # 5 was due to have the communicable disease trainings no later than February 6, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Human Resources Manager has been instructed by Project Director to schedule the 6 hour HIV/AIDS training and the 4 hours of TB/STD and other health related topics as soon as possible. Employees who need to participate in this training will be required to attend on the scheduled date. It is anticipated that the training will be conducted on or before June 30, 2023. The Human Resources Manager will be responsible for scheduling both trainings on an annual basis as of April 20, 2023. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee # 4 was hired as a counselor on October 6, 2022 and was still in this position at the time of the inspection. There was no documentation of training to perform assigned tasks during an emergency in the employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Manager will ensure that each staff hired to work in the project will be trained to perform assigned tasks during an emergency, in addition to fires specifically, on their date of hire. Any staff member who does not currently have training to perform assigned tasks during an emergency will complete the training by April 28, 2023. The Project Director will request confirmation of this training on May 1, 2033. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on six out of seven client records reviewed, the facility failed to provide a psychosocial evaluation in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a psychosocial evaluation be completed at the intake session.
Client # 1 was admitted on January 13, 2023 and was still active at the time of the inspection. The intake appointment occurred on January 13, 2023. The psychosocial evaluation did not occur until January 26, 2023.
Client # 2 was admitted on December 19, 2022 and was still active at the time of the inspection. The intake appointment occurred on January 13, 2023. The psychosocial evaluation did not occur until January 26, 2023.
Client # 3 was admitted on December 22, 2022 and was still active at the time of the inspection. The intake appointment occurred on December 22, 2022. The psychosocial evaluation did not occur until December 28, 2022.
Client # 4 was admitted on November 17, 2022 and was discharged on March 13, 2023. The intake appointment occurred on November 17, 2022. The psychosocial evaluation did not occur until December 27, 2022.
Client # 5 was admitted on December 8, 2022 and was discharged on January 20, 2023.
The intake appointment occurred on December 9, 2022. The psychosocial evaluation did not occur until December 14, 2022.
Client # 6 was admitted on June 23, 2022 and was discharged on October 4, 2022.
The intake appointment occurred on June 30, 2022. The psychosocial evaluation did not occur until July 15, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will update the policy manual to reflect that the psychosocial evaluation be completed by the third session. The update to the manual will be made by 4/21/23 and staff will be reminded of this policy at the April 21, 2023 staff meeting. The Clinical Supervisor and Project Director will monitor client records monthly to ensure that the psychosocial evaluations are completed by the third session starting on April 21, 2023. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on three out of seven client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a preliminary treatment plan be completed at the intake session.
Client # 1 was admitted on January 13, 2023 and was still active at the time of the inspection. The intake appointment occurred on January 13, 2023. The preliminary treatment plan did not occur until February 27, 2023.
Client # 2 was admitted on December 19, 2022 and was still active at the time of the inspection. The intake appointment occurred on January 13, 2023. The preliminary treatment plan did not occur until February 27, 2023.
Client # 7 was admitted on August 17, 2022 and was discharged on November 22, 2022.
The intake appointment occurred on August 17, 2022. There was no documentation of a preliminary treatment plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will conduct a training during the staff meeting on 4/21/2023 regarding the preliminary treatment plan. The staff will be reminded that the preliminary treatment plan is to be completed at the intake session. The Clinical Supervisor will review records weekly to ensure that the preliminary treatment plan is completed during the first session as of April 21, 2023. |