INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection conducted on February 10, 2021, 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(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 the review of personnel records, the facility failed to provide documentation of TB/STD training in one of one personnel record.
Employee #4 was hired as a counselor on February 4, 2019. The TB/STD training documentation was due by February 4, 2020. TB/STD training documentation was not available 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
The Clinical Director will schedule the 6 HIV/AIDS training and the 4 hour tuberculosis, sexually transmitted diseases and other health related topics training in collaboration with the HR Manager by March 15,2021. Both the 6 and 4 hour trainings will be held as soon as possible, no later than April 30, 2021. The staff who are overdue for the training will attend no later than April 30, 2021. The HR Manager will ensure that both the 6 HIV/AIDS training and the 4 hour tuberculosis, sexually transmitted diseases and other health related topics training are scheduled twice per year in order to ensure continued compliance with the requirements. The HR Manager will also ensure that documentation of attendance at trainings is maintained in the personnel records. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The fire drill logs were reviewed for the time of January 2019 to January 2021. An overnight fire drill was due to be completed in February 2020. There was no overnight fire drill documented for February, 2020.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 2, 2019 annual inspection.
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Plan of Correction
In order to address the deficiency for 705.10 (d) (5), Fire Safety, the agency will ensure that sleeping hours fire drills are conducted at minimum of once every 6 months.
The Residential Manager and Program supervisor will conduct monthly fire drills and place the written documents in the designated location to be reviewed by Outside In's Compliance manager.
In order to maintain compliance with this regulation, the Residential Manager and/or the Program Supervisor will complete a sleeping hours fire drill prior to May 19th, 2021, as the most recent sleeping hours drill was conducted on November 19th, 2020. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to document it notified the client, in writing, of the decision to involuntarily terminate the client in one of one client record.
Client # 4 was involuntarily terminated from the facility on August 30, 2020. There was no documentation the client was notified, in writing, of the decision to terminate.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 31, 2021, the Clinical Supervisor will ensure that any client who is subject to involuntary termination is notified in writing of the decision to involuntarily terminate treatment. The Clinical Supervisor will ensure that the client is notified of the reason for and right to appeal the decision to involuntarily terminate treatment. Clients who are subject to involuntary termination will sign off on this notification. Clinical staff will be trained on the involuntary termination of treatment procedures by March 31, 2021. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility to document it notified the client of the opportunity request reconsideration of a decision terminating treatment in one of one client record.
Client # 4 was involuntarily terminated from the facility on August 30, 2020. There was no documentation the client was provided the opportunity to request reconsideration of a decision terminating treatment
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 31, 2021, the Clinical Supervisor will ensure that any client who is subject to involuntary termination is notified in writing of the decision to involuntarily terminate treatment. The Clinical Supervisor will ensure that the client is notified of the reason for and right to appeal the decision to involuntarily terminate treatment. Clients who are subject to involuntary termination will sign off on this notification. Clinical staff will be trained on the involuntary termination of treatment procedures by March 31, 2021. |