INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2024 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 Experimental 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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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every thirty days in two of three applicable records.Client #4 was admitted on June 29, 2023 and discharged on October 3, 2023. A treatment plan update was completed on July 12, 2023 and the next update was due no later than August 12, 2023; however, it was not completed prior to discharge.Client #7 was admitted on September 27, 2023 and discharged on November 16, 2023. A treatment plan update was completed on October 4, 2023 and the next update was due no later than November 4, 2023; however, it was not completed prior to discharge.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the March 30, 2023 annual licensing inspection.
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Plan of Correction
The Project Director will provide training regarding the frequency and timeframes for treatment plan review and updates during the staff meeting on April 12, 2024. The Clinical Supervisor will conduct random monthly chart audits to ensure adherence to this requirement. The Clinical Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in three of seven records.Client #1 was admitted on January 26, 2024 and was still active at the time of the inspection. The treatment plans dated January 26, 2024 and February 15, 2024 indicated one hour of family therapy once to twice per month. There was no documentation of the client receiving family therapy between January 26 - March 12, 2024. Client #4 was admitted on June 29, 2023 and discharged on October 3, 2023. The treatment plan dated February 12, 2024, and all updated treatment plans, indicated one hour of family therapy once to twice per month. There was no documentation that the client received family therapy in September 2023. Client #5 was admitted on June 30, 2023 and discharged on August 10, 2023. The treatment plan dated June 30, 2023, and all updated treatment plans, indicated one hour of individual therapy weekly. There was no documentation that the client received individual therapy between July 14 -August 10, 2023.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will provide training regarding how to ensure that clients received counseling services according to their individual treatment plan during the staff meeting on April 12, 2024. The individual treatment plan should reflect the counseling services received by the client per ASAM requirements and individual circumstances. The frequency and dose of services should be reviewed with the Clinical Supervisor in supervisory meetings. The Project Director and/or Clinical Supervisor will review individual treatment plans using random monthly audits to ensure adherence to this requirement. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in one of two discharged records.The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 30 days.Client #4 was admitted on June 29, 2023 and discharged on October 3, 2023. Follow-up was to be completed by November 3, 2023, but was not completed until November 7, 2023.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will provide training regarding follow up policy and procedure during the April 12, 2024 staff meeting. The follow up call must be made within 30 days of discharge. The Clinical Supervisor will utilize random monthly chart audits to ensure adherence to this requirement. The Clinical Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors. |