INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30, 2022 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(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. |
704.12(a)(3)(ii) LICENSURE NonHosp Rehab/Adol
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(ii) Projects serving adolescent clients shall have one FTE counselor for every six clients.
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Observations
Based on review of the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of the FTE (full-time equivalent) counselor caseload for the adolescent residential program not exceeded one FTE counselor for every six active clients.
The counselor Full Time Equivalent (FTE) for a residential program is determined by dividing the total number of hours the counselor's devote to their clients by the facility's hours of operation eg. 37.5. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation is as follows: 120/40= 3(FTE); 21/3= 7, which equals to a client/counselor ratio of 7:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 1, the agency will have another employee hired to work as a counselor in the facility which will make the FTE counselor caseload one FTE counselor for every six active clients. The Project Director and Clinical Supervisor will train the employee and the employee will be able to carry a full caseload by June 1, 2023. To ensure that this deficiency does not recur, the Human Resources Manager will continue to screen potential applicants and the Project Director will approve the hire of a second qualified candidate as soon as a qualified applicant is known to the agency. Agency leadership has considered several action steps to improve our hiring, recruitment and training needs. The Human Resources Manager has connected with applicants at local job fairs, refreshes the posting on Indeed, and is making the local colleges and universities aware of our employment opportunities. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on one of one applicable client record reviewed, the facility failed to provide documentation of the client's emergency contact being notified in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicates an emergency contact be notified within 12 hours of the client leaving the facility against facility advice.
Client # 7 was admitted on May 26, 2022 and discharged July 8, 2022. There was no documentation of the emergency contact being notified in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the staff meeting on April 26, 2023, the Project Director will conduct a training for the team regarding a client's emergency contact to be notified within 12 hours of the client leaving the facility against facility advice (AFA). The team will be reminded that the notification must be made within 12 hours of the AFA and must be documented in the client record using the applicable form. The form will be shared with the team during the training as a reminder. In order to ensure that this deficiency does not recur, the Clinical Supervisor will be aware of any client who leaves treatment against facility advise and will be responsible for reviewing the client record to ensure that the emergency contact has been notified within one hour of the client's departure. If the emergency contact notification has not yet been made, the Clinical Supervisor will make the notification per agency policy at that time. |
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 one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in client record # 5.
Client # 5 was admitted on December 6, 2022 and discharged on January 26, 2023. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the staff meeting on April 26, 2023, the Project Director will conduct a training for the team regarding client notification, in writing, of a decision to involuntarily terminate a client's treatment. The team will be reminded that the notification must be documented in the client record using the applicable form. The form will be shared with the team during the training as a reminder. In order to ensure that this deficiency does not recur, the Clinical Supervisor will review the record of any client who is pending involuntary discharge and ensure that the documentation in the record is completed according to agency policy. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on six of seven client records reviewed, the facility failed to provide documentation of orienting the client to the project to include a familiarization with the hours of operation in client records # 2, 3, 4, 5, 6, and 7.
Client # 2 was admitted on January 23, 2023 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the hours of operation.
Client # 3 was admitted on February 13, 2023 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the hours of operation.
Client # 4 was admitted on December 13, 2022 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the hours of operation.
Client # 5 was admitted on December 6, 2022 and was discharged January 26, 2023. There was no documentation of the client being familiarized with the hours of operation.
Client # 6 was admitted on November 10, 2022 and was discharged February 27, 2023. There was no documentation of the client being familiarized with the hours of operation.
Client # 7 was admitted on May 26, 2022 and was discharged July 8, 2022. There was no documentation of the client being familiarized with the hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will update the notification of services form and the client handbook to reflect the accurate hours of operation for the project overall and for the clinical team by May 1, 2023. The client handbook will reflect the name of the client's individual counselor along with the counselor's general work schedule. The notification of services will include the work schedules of the counseling team in general. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on six of seven client records reviewed, the facility failed to provide documentation of orienting the client to the project to include a familiarization with the fee schedule in client records # 2, 3, 4, 5, 6, and 7.
Client # 2 was admitted on January 23, 2023 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the fee schedule.
Client # 3 was admitted on February 13, 2023 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the fee schedule.
Client # 4 was admitted on December 13, 2022 and was still active at the time of the inspection. There was no documentation of the client being familiarized with the fee schedule.
Client # 5 was admitted on December 6, 2022 and was discharged January 26, 2023. There was no documentation of the client being familiarized with the fee schedule.
Client # 6 was admitted on November 10, 2022 and was discharged February 27, 2023. There was no documentation of the client being familiarized with the fee schedule.
Client # 7 was admitted on May 26, 2022 and was discharged July 8, 2022. There was no documentation of the client being familiarized with the fee schedule.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will update the client handbook and notification of services form to reflect the fee schedule for the facility as of May 1, 2023. This update will include the reimbursement rate from MCOs and what a client should expect to pay if insurance did not cover the cost of treatment. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on six 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 17, 2023 and was still active at the time of the inspection. The intake appointment occurred on January 17, 2023. The psychosocial evaluation did not occur until January 27, 2023.
Client # 2 was admitted on January 23, 2023 and was still active at the time of the inspection. The intake appointment occurred on January 23, 2023. The psychosocial evaluation did not occur until February 1, 2023.
Client # 3 was admitted on February 13, 2023 and was still active at the time of the inspection. The intake appointment occurred on February 13, 2023. The psychosocial evaluation did not occur until February 22, 2023.
Client # 4 was admitted on December 13, 2023 and was still active at the time of the inspection. The intake appointment occurred on December 21, 2022. The psychosocial evaluation did not occur until December 23, 2022.
Client # 5 was admitted on December 6, 2022 and was discharged on January 26, 2023. The intake appointment occurred on December 6, 2022. The psychosocial evaluation did not occur until December 15, 2022.
Client # 7 was admitted on May 26, 2022 and was discharged on July 8, 2022.
The intake appointment occurred on May 26, 2022. The psychosocial evaluation did not occur until June 2, 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 client's 14th day in treatment. The update to the manual will be made by 4/21/23 and staff will be reminded of this policy at the April 26, 2023 staff meeting. The Clinical Supervisor will conduct random monthly chart audits to ensure compliance with this requirement and will provide individual coaching and documentation of deficiency if needed. |
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 three of seven client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in client records # 2, 5 and 6.
Client # 2 was admitted on January 23, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 5, 2023. A treatment and rehabilitation plan update was due no later than March 5, 2023. A treatment and rehabilitation plan update did not occur until March 26, 2023.
Client # 5 was admitted on December 6, 2022 and was discharged on January 26, 2023. A treatment and rehabilitation plan was developed on December 18, 2022. A treatment and rehabilitation plan update was due no later than January 18, 2023. There was no documentation of a treatment plan update in the client record.
Client # 6 was admitted on November 10, 2022 and was discharged on February 27, 2023. A treatment and rehabilitation plan was developed on November 26, 2022. A treatment and rehabilitation plan update was due no later than December 26, 2022. A treatment and rehabilitation plan update did not occur until January 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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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 26, 2023. 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. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 10 days of discharge.
Client # 6 was admitted on November 10, 2022 and was discharged on February 27, 2023. The discharge summary was due to be completed no later than March 9, 2023. The discharge summary was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will provide training regarding the the due date for discharge summaries during the staff meeting on April 26, 2023. 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. |