INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4, 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 Pathway to Recovery Outpatient Services, 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. |
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 a review of personnel records, the facility failed to ensure two employees received the minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment in two of two applicable records.
Staff #4 was hired as a counselor on May 1, 2023, and still employed at time of inspection. Staff #4 was due to have the communicable disease trainings no later than May 1, 2024. The HIV/AIDS was not completed until December 4, 2024, and there was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
Staff #5 was hired as a counselor on October 30, 2023, and still employed at time of inspection. Staff #5 was due to have the communicable disease trainings no later than October 30, 2024. There was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director and Clinical Supervisor will facilitate the TB/STD training on April 10, 2025. Employees who have not yet attended this training will be required to attend and other employees can attend as a refresher if needed. The Project Director and Clinical Supervisor will offer this training annually in order to ensure that any new hires meet the regulation requirement. The HR Assistant will monitor compliance with training requirements and notify the Project Director of any unmet training requirements. |
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 two of seven records.
There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #1 was admitted on June 13, 2024, and discharged on October 8, 2024.
Client #3 was admitted on July 11, 2024, and discharged on December 19, 2024.
These findings were 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. Clinical Supervisors will be responsible for reviewing each record for compliance with documentation standards monthly. |
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 June 13, 2024, and discharged on October 8, 2024. The treatment plan was dated July 3, 2024.
Client #2 was admitted on September 6, 2024, and discharged on January 21, 2025. The treatment plan was dated October 7, 2024.
Client #3 was admitted on July 11, 2024, and discharged on December 19, 2024. The treatment plan was dated August 15, 2024.
Client #4 was admitted on June 14, 2024, and discharged on October 28, 2024. The treatment plan was dated July 15, 2024.
Client #5 was admitted on November 12, 2024, and was still active at the time of the inspection. The treatment plan was dated January 7, 2025.
Client #6 was admitted on December 5, 2024, and was still active at the time of the inspection. The treatment plan was dated February 13, 2025.
Client #7 was admitted on January 13, 2025, and was still active at the time of the inspection. The treatment plan was dated February 14, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 13, 2024, licensing inspection.
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Plan of Correction
The Project Director will reach out to the staff at our electronic health record provider and determine if a field for "proposed type of support service" can be added to the treatment plan by March 14, 2025. 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 "proposed type of 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 three of five applicable records.
Client #1 was admitted on June 13, 2024, and discharged on October 8, 2024. A treatment plan was completed on July 3, 2024, and the update was due no later than September 3, 2024; however, the update was completed on September 10, 2024.
Client #2 was admitted on September 6, 2024, and discharged on January 21, 2025. A treatment plan update was completed on November 6, 2024, and the next update was due no later than January 6, 2025; however, it was completed on January 20, 2025.
Client #3 was admitted on July 11, 2024, and discharged on December 19, 2024. A treatment plan update was completed on October 15, 2024, and the next update was due no later than December 15, 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 13, 2024, licensing inspection.
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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. |