INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 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 one of seven records.
There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #6 was admitted on October 17, 2024, 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. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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 seven of seven records.
Client #1 was admitted on July 2, 2024, and discharged on October 22, 2024. The treatment plan was dated August 9, 2024.
Client #2 was admitted on September 12, 2024, and discharged on February 26, 2025. The treatment plan was dated October 15, 2024.
Client #3 was admitted on July 16, 2024, and discharged on December 12, 2024. The treatment plan was dated August 1, 2024.
Client #4 was admitted on November 21, 2024, and discharged on February 11, 2025. The treatment plan was dated December 17, 2024.
Client #5 was admitted on December 12, 2024, and was still active at the time of the inspection. The treatment plan was dated January 9, 2025.
Client #6 was admitted on October 17, 2024, and was still active at the time of the inspection. The treatment plan was dated October 29, 2024.
Client #7 was admitted on October 31, 2024, and was still active at the time of the inspection. The treatment plan was dated December 11, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 11, 2024, licensing inspection.
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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. |
709.92(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 a review of client records, the facility failed to document treatment plan updates every 60 days in two of six applicable records.
Client #2 was admitted on September 12, 2024, and discharged on February 26, 2025. A treatment plan update was completed on December 12, 2024, and the next update was due no later than February 12, 2025; however, it was completed on February 26, 2025.
Client #3 was admitted on July 16, 2024, and discharged on December 12, 2024. A treatment plan update was completed on September 26, 2024, and the next update was due no later than November 26, 2024; however, there were no further updates in client #3 ' s record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 11, 2024, March 28, 2023, March 16, 2022, and February 12, 2021, licensing inspections.
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Plan of Correction
The Project Director will coach the team regarding treatment plan updates at the next scheduled staff meeting on March 21, 2025. All outpatient treatment plans must be reviewed every 60 by the assigned clinician. The team will be reminded that clients do not need to be present for the treatment plan reviews and that the reviews should be shared with the client in an upcoming session. The Clinical Supervisor will monitor compliance with documentation standards by conducting monthly record reviews. The Project Director will ensure that the existing policy reflects this information and make modifications if needed by March 21, 2025. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for treatment plan updates were submitted and approved by the Department for the March 11, 2024, March 28, 2023, March 16, 2022, and February 12, 2021, annual licensing inspections. Treatment plan updates were again found to be a deficiency in the March 7, 2025, annual licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 11, 2024, licensing inspection.
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Plan of Correction
The Project Director and Clinical Supervisors will educate staff regarding the procedure for timely treatment plan updates during the 3/21/25 staff meeting and continue to monitor during case review supervision. The team has been under the impression that DDAP required the client to be present at the time of the treatment plan review and the Project Director recently learned that this is not accurate. As a result, the counselors will be responsible for completing reviews every 60 days with a reminder being issued by the Clinical Supervisor at the 45 day mark. Counselors will then review the update with clients in the next session that the client attends. We will monitor compliance with this expectation and expect that the shift from requiring the client to be present for the review to resolve further issues with this requirement. |