INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 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. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee # 4 was hired as a counselor on October 19, 2022 and was still in this position at the time of the inspection. There was no documentation of training to perform assigned tasks during an emergency in the employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Manager will ensure that each staff hired to work in the project will be trained to perform assigned tasks during an emergency, in addition to fires specifically, on their date of hire. Any staff member who does not currently have training to perform assigned tasks during an emergency will complete the training by April 28, 2023. The Project Director will request confirmation of this training on May 1, 2033. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.
Client # 3 was admitted on September 20, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a county office did not have a valid signature by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will train and remind the staff that all informed and voluntary consent forms in the client record must include a dated signature of the client during the staff meeting on April 21, 2023. The Clinical Supervisor will review client records monthly to ensure compliance with this requirement effective April 20, 2023. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on one out of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include documentation of a client consent being offered to the client.
Client # 2 was admitted on January 17, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated January 17, 2023 to a funding agency did not include documentation of the client consent being offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will train and remind the staff that all informed and voluntary consent forms in the client record must include documentation of a client consent being offered to the client during the staff meeting on April 21, 2023. The Clinical Supervisor will review client records monthly to ensure compliance with this requirement effective April 20, 2023. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on five out of six 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 # 2 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 February 16, 2023.
Client # 3 was admitted on September 20, 2022 and was still active at the time of the inspection. The intake appointment occurred on September 20, 2022. The psychosocial evaluation did not occur until October 17, 2022.
Client # 5 was admitted on September 14, 2022 and was discharged on March 13, 2023. The intake appointment occurred on September 14, 2022. The psychosocial evaluation did not occur until November 7, 2022.
Client # 6 was admitted on November 3, 2022 and was discharged on February 16, 2023.
The intake appointment occurred on November 3, 2022. The psychosocial evaluation did not occur until December 21, 2022.
Client # 7 was admitted on January 9, 2023 and was discharged on February 6, 2023.
The intake appointment occurred on January 9, 2023. There was no psychosocial evaluation in the client record.
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 third session. The update to the manual will be made by 4/21/23 and the Project Director will remind staff of this policy at the April 21, 2023 staff meeting. In order to ensure that this deficiency does not recur, the Clinical Supervisor will conduct weekly randomized chart reviews. The results of the chart reviews will be discussed in supervision. Failure to abide by the chart requirements will result in coaching and potential disciplinary action. |
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 one of three applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client record # 3.
Client # 3 was admitted on September 20, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on October 17, 2022. A treatment and rehabilitation plan update was due no later than December 17, 2022. A treatment and rehabilitation plan update did not occur until January 4, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 12, 2021 and March 16, 2022 annual licensing inspection.
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Plan of Correction
The Project Director will re-train the staff regarding the requirement to review and update the treatment and rehabilitation plan at least every sixty days during the staff meeting on April 21, 2021. The Clinical Supervisor and Project Director will closely monitor client records for compliance for the next 2 months and document any failure to follow the policy in the employee's HR file. The Clinical Supervisor will remind each counselor of the upcoming treatment plan review dates in individual supervision as well and this standard will become part of our procedures as of May 1, 2023. |
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.
Plans of correction for treatment plan updates were submitted and approved by the Department for the February 12, 2021 and March 16, 2022 annual licensing inspections. Providing treatment plan updates every sixty days were again found to be a deficiency in the March 28, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Failure to follow the plan of correction is related to staff training and retention. The Project Director will meet with agency leadership and further develop the goal of staff retention in the project's strategic plan. The Project Director has met with Human Resources and developed a specific training regarding how to manage treatment planning due dates and benchmarks. The training will be provided to all current employees by June 1, 2023 and will be added to the training calendar quarterly for refreshers. The Clinical Supervisor will be responsible for facilitating the training with assistance from the Project Director. |