INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection conducted on February 11, 2021, Outside-In Pathway to Recovery Outpatient 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.
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Plan of Correction
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent for the specific information to be disclosed, in two of seven client records.
Client records # 4 and 5 documented releases for the third-party payor that exceeded the parameters of 255.5.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
During a training held on February 23, 2021, the Clinical Director reviewed parameters for an informed and voluntary consent with emphasis on the specific information to be disclosed. The Clinical Director explained the parameters of 255.5 and the importance of using the proper informed and voluntary consent forms. The Clinical Supervisor will monitor compliance and ensure that this deficiency does not recur by conducting monthly chart audits. The Clinical Director will review quarterly chart audit reports in order to ensure compliance. Clinical counseling staff are responsible for obtaining the correct informed and voluntary consent for the specific information to be disclosed. |
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 the review of client records, the facility failed to document the treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of six client records.
Client # 2 had a treatment plan update that was due to be completed by January 13, 2021. The update was completed on February 4, 2021.
Client # 5 had treatment plan updates that was due to be completed by August 18 and October 18, 2020. There were no updates documented.
Client # 6 had treatment plan updates that was due to be completed by August 19 and October 19, 2020. There were no updates documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director trained all clinical staff on the importance of documenting that treatment plans were reviewed and updated at least every 60 days on February 23, 2021. The Clinical Supervisor will monitor compliance with documenting that treatment plans were reviewed and updated at least every 60 days during weekly chart audits with counselors in supervision sessions on an ongoing basis. The administrative assistant will send treatment plan update reminder messages to the staff on an ongoing basis. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan in three of four client records.
Client # 5 was successfully discharged on November 13. 2020. There was no aftercare plan documented.
Client # 6 was successfully discharged on October 29, 2020. There was no aftercare plan documented.
Client # 7 was successfully discharged on July 1. 2020. There was no aftercare plan documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a training held on February 23, 2021, the Clinical Director reviewed the agency policy on aftercare planning and documentation of aftercare plans with the team. Each client is to have a completed aftercare plan in the record before discharge from the program. The Clinical Supervisor will ensure that aftercare plans are complete in the record before the case is closed by conducting weekly chart audits during supervision on an ongoing basis. |
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 the review of client records, the facility failed to document follow-up in four of four client records.
Per agency policy, follow-up is to be completed with 7 days of discharge.
Client # 4 was discharged on January 28, 2021. There was no follow-up documented.
Client # 5 was discharged on November 13, 2020. There was no follow-up documented.
Client # 6 was discharged on October 29, 2020. There was no follow-up documented.
Client # 7 was discharged on July 1, 2020. There was no follow-up documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a training held on February 23, 2021, the Clinical Director reviewed the agency's follow up policy with the team. The follow-up must be complete within 7 days of discharge. The Clinical Supervisor will ensure that follow-ups are complete and will use the computer system to remind counselors of follow up due dates on an ongoing basis. |