INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5, 2025, 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 School of Experiential Education, 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administrative information, the facility failed to collect feedback on completed trainings.
Facility policy and procedures state that feedback forms are to be completed after each training.
The training year beginning July 1, 2023, through June 30, 2024, was reviewed and feedback was not collected for any training.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will amend the existing policy regarding training feedback forms to indicate that feedback will be gathered quarterly regarding training by April 1, 2025. On April 1, 2025, each employee will be asked to provide feedback quarterly on the trainings they attended in the past quarter on a feedback form. The HR Assistant will email the form to employees quarterly and encourage a timely response. The HR department will maintain a record of the feedback provided and the HR Assistant will monitor that the feedback is being collected quarterly. The Project Director will use the feedback when developing the project's annual training plan. This amended policy will be effective April 1, 2025. The HR Assistant will notify the Project Director of any lapse in feedback being obtained. The Project Director will address and document any lapse in feedback with employees in a face to face meeting. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two of seven records.
There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
Client #5 was admitted on January 14, 2025, and was still active at the time of the inspection.
Client #6 was admitted on January 31, 2025, and was still active at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director and Clinical Supervisors will remind all staff of the importance of obtaining consent to release information for funders during the next scheduled staff meeting on March 21, 2025. The assigned counselors will obtain consent to release information to funders on any active client record by March 28, 2025. The Clinical Supervisor will monitor compliance with documentation standards by conducting monthly record reviews. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in two of six applicable records.
Client #2 was admitted on September 19, 2024, and discharged on December 4, 2025. The treatment plan was dated September 30, 2024.
Client #6 was admitted on January 31, 2025, and was still active at the time of the inspection. The treatment plan was dated February 10, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
"Potential support service" can be added to the treatment plan by our electronic health record provider. The team will be coached regarding support services on treatment plans during the next scheduled staff meeting on March 21, 2025. The team will be advised that the client's treatment plan must include "potential support services" as of March 21, 2025 by adding this to the existing "strengths" field on the plan until a separate field for this information can be added to the treatment plan. The Clinical Supervisor will monitor compliance with documentation standards by conducting monthly record reviews. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in two of six applicable records reviewed.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in the following records:
Client #5 was admitted on January 14, 2025, and was still active at the time of the inspection.
Client #6 was admitted on January 31, 2025, and was still active at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During the March 21, 2025 staff meeting, staff will be reminded that any work done by the clients at the project is an integral part of his treatment and rehabilitation plan and needs to be reflected in the treatment plan. Staff can use the following example as in intervention on the treatment plan "Participate in work projects that strengthen work ethic and connect service work to recovery." The Clinical Supervisor will conduct monthly chart reviews and ensure compliance with this requirement. |