INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on November 13, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Performance Is Attitude LP 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the Facility Director meets the qualifications for their position in one of one record.
Staff #2 was hired as Facility Director on March 1, 2024 but did not meet the education requirements.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Date of Plan: 12/17/2024
Issue Identified:
The current Facility Director does not meet the qualifications required for the position as outlined by regulatory standards. #0025
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1. Corrective Action to Address the Deficiency
Action Plan:
- Immediate Interim Measures:
o Project Director will be appointed immediately. The Project Director possesses the required credentials and qualifications as per regulatory standards to temporarily oversee the operations of the facility.
- Permanent Resolution:
o The Project Director will undergo a thorough review of the qualifications of the Facility Director Candidate to identify the gaps. This will include verifying educational background, experience, and certifications.
o If additional training, certification, or education is required, the Facility Director will be enrolled in the necessary programs.
o If the current director is unable to meet the qualifications after the review and necessary interventions, the facility will initiate a search for a qualified individual to fill the role permanently.
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2. Steps to Prevent Recurrence
Action Plan:
- Hiring and Onboarding Procedures:
o The facility will implement a more robust screening and verification process during the hiring of future Facility Directors to ensure they meet all necessary qualifications from the outset. This will include:
Reviewing all required qualifications (educational, professional experience, certifications).
Performing reference checks and verifying credentials.
o A detailed checklist of required qualifications will be added to the hiring procedures to ensure future candidates meet all necessary criteria.
- Ongoing Monitoring of Qualifications:
o The Human Resources (HR) department will conduct annual reviews of the qualifications of the Facility Director and key staff members to ensure compliance with regulatory requirements.
o Any changes in qualifications or licensure will be monitored and addressed promptly.
- Staff Training:
o HR and the Board of Directors will provide training for leadership staff on the importance of maintaining qualifications and how to assess staff credentials regularly.
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3. Date of Completion of Corrective Action
Immediate Action Completion:
- The Facility Director will be replaced by 12/17/2024, and the review of qualifications for the new Facility Director will be completed by 1/17/2025.
Permanent Corrective Action Completion:
- If additional qualifications or certifications are needed for the Facility Director candidate, they will be completed no later than 1/17/2025.
- If a new Facility Director is required, the search and hiring process will be concluded by 2/17/2025.
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4. Responsible Person for Implementation
- Responsible Person: Project Director
Role: To oversee and ensure the corrective action is fully implemented, including the appointment of an interim director, qualifications review, necessary training, and long-term preventative measures.
- Responsible for Verification and Oversight: CEO
Role: To verify that corrective actions have been completed on time and ensure that the facility continues to meet all required standards moving forward.
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CEO
12/17/2024
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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 personnel records, the facility failed to develop a written individual training plan for each employee in two of two records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Date of Plan: 12/17/2024
Issue Identified:
The facility currently does not have a written individual training plan for each employee, appropriate to their skill level. Additionally, the plans are not being developed annually with input from both the employee and the supervisor. #0063
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1. Corrective Action to Address the Deficiency
Action Plan:
- Individual Training Plans (ITP):
o The facility will create a written Individual Training Plan (ITP) for each employee, tailored to their specific role and skill level. These plans will be developed in collaboration with both the employee and their supervisor, ensuring that individual goals, competencies, and areas for improvement are clearly identified.
o Each ITP will include:
A list of specific training needs or areas for development based on job requirements, employee performance, and regulatory standards.
Clear goals and objectives for the employee's professional development.
A timeline for completion of each training module, certification, or skill-building activity.
A method for evaluating progress and effectiveness of the training.
- Annual Review and Development:
o The ITPs will be reviewed and updated annually, in collaboration with each employee and their supervisor. This ensures that the training plan reflects both the evolving needs of the employee and any updates to the facility's regulatory requirements.
o Supervisors will hold a meeting with each employee to discuss their ITP and set new development goals for the upcoming year.
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2. Steps to Prevent Recurrence
Action Plan:
- Implementation of a Structured Staff Development Program:
o The facility will implement a standardized, structured staff development program that requires the development of ITPs for all employees. The program will include regular training sessions, workshops, and access to certifications relevant to the roles within the facility.
o The HR department will ensure that all new hires and current employees are provided with an initial ITP upon hire and that it is updated annually thereafter.
- Documentation and Tracking:
o The HR department will maintain a centralized database to track the completion and progress of ITPs. This will help ensure that training is up-to-date and that no employee's development plan is overlooked.
o Supervisors will be required to submit signed copies of updated ITPs annually, and the HR department will be responsible for monitoring compliance.
- Ongoing Supervisor and Employee Engagement:
o Supervisors will be trained to collaborate effectively with employees in the development of ITPs and to provide feedback on their progress throughout the year.
o Supervisors will schedule quarterly check-ins with employees to review training progress, adjust goals as needed, and identify any challenges to achieving training objectives.
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3. Date of Completion of Corrective Action
Immediate Action Completion:
- The initial Individual Training Plans for each employee will be developed and documented by January 1, of every year.
- Supervisors will begin the annual review process and update all ITPs by the 25th of every month and will conclude by December 20 of every year.
Ongoing Process:
- The staff development program and the process for developing ITPs will be fully implemented, and the first annual update of all ITPs will be completed by 1/25/2025.
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4. Responsible Person for Implementation
- Responsible Person: Project Director
Role: To oversee and ensure the implementation of the staff development program, including the creation of ITPs for each employee, the tracking of training progress, and the annual review process.
- Responsible for Supervisory Oversight: CEO
Role: To ensure that ITPs are developed in collaboration with each employee, that training goals are being met, and that employees receive the necessary resources and support to complete their development plans.
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CEO
12/17/2024
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of administrative records and facility staff interview, the facility failed to conduct unannounced fire drills at least once a month.
No fire drills were conducted between March 2024 through October 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
#P273
Fire Drill Chart
Facility Name: Performance Is Attitude LP
Facility Address: 351-355 5th Ave Suites 309-310 Pittsburgh, Pa 15222-2405
Date of Plan: 12/17/2024
This chart will be used to track and record unannounced fire drills conducted monthly at the outpatient drug and alcohol facility. It ensures compliance with safety regulations and documentation of each fire drill, including participants, observations, and corrective actions if necessary.
Month Date of Drill Time of Drill Conducted By No. of Persons in Facility During Fire Drill Exit Route Used Duration of Drill Fire Alarm/Smoke Detector Operative Corrective Actions (if any) Supervisor/Director Signature
January [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
February [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
March [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
April [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
May [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
June [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
July [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
August [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
September [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
October [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
November [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
December [MM/DD/YYYY] [HH:MM AM/PM] [Name/Title] [No. of Persons] [Exit Route Used] [Duration] [Yes/No] [Actions] [Signature]
Explanation of Columns:
1. Month: The month when the fire drill is conducted.
2. Date of Drill: The exact date the fire drill was held (e.g., 01/15/2024).
3. Exit Route Used: Where did person(s) exit the building
4. Conducted By: The person(s) responsible for organizing and overseeing the drill (e.g., Facility Manager, Safety Officer).
5. Number of Persons in the Facility: List of staff members who participated in the drill (e.g., administrative staff, clinical team, support staff).
6. Fire alarm/smoke detectors operative: A brief description of the scenario simulated during the fire drill (e.g., "Are the fire alarms working," "Smoke detectors operating correctly").
7. Duration of Drill: The total time taken to complete the drill (e.g., 5 minutes, 10 minutes).
8. Safety Issues/Observations: Any issues that arose during the drill (e.g., staff unprepared, equipment malfunction, unclear evacuation route).
9. Corrective Actions: Actions to address any issues noted during the drill (e.g., additional training for staff, update evacuation plan, maintenance of fire alarm system).
10. Supervisor/Director Signature: Signature of the supervisor or facility director who verifies that the drill was conducted and any corrective actions have been taken.
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Instructions for Use:
- Unannounced Drills: All fire drills must be unannounced to staff to ensure realistic practice in an emergency.
- Monthly Drills: A fire drill must be conducted each month, and this chart will be used to track the drill details.
- Review and Evaluation: The fire drill chart should be reviewed by the Facility Director or Safety Officer to evaluate staff preparedness and identify areas for improvement.
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The Facility Project Director will review the unannounced Fire Drill logs on the 1st of every month to ensure that this policy is implemented. This Fire Drill Chart will be kept in a central location for reference and auditing, and a copy will be provided to relevant authorities upon request.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of administrative information, the facility failed to provide procedures to include the identification of the person responsible for maintenance of client records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Date of Plan: 12/17/2024
Issue Identified:
The Facility has not identified a specific individual or position responsible for maintaining confidentiality of client identity and records, which is a violation of regulatory requirements for safeguarding sensitive client information. #0271
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1. Corrective Action to Address the Deficiency
Action Plan:
- Designation of Responsible Person:
o The Facility formally designates the Project Director responsible for ensuring maintaining confidentiality of client identity and records. This person will be accountable for ensuring that all client information is maintained and handled in compliance with confidentiality regulations (e.g., 709.28(a)(1) HIPAA, 42 CFR Part 2).
o The designated individual or position will be clearly identified in the facility's written policies and procedures related to confidentiality. The Project Director will take the following steps to ensure that this policy is followed:
Ensuring all staff members are trained on confidentiality policies.
Monitoring access to client records and ensuring secure storage.
Responding to any breaches or potential confidentiality violations.
- Update Policies and Procedures:
o The facility will update its written policies and procedures to include the job title of the individual responsible for confidentiality. These procedures will also outline specific protocols for managing, storing, and sharing client records securely.
o The policy will also include guidelines for training all new and current staff on confidentiality requirements, ensuring they understand their roles in maintaining client privacy.
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709.84(f)(1) LICENSURE Project management services
709.84. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of administrative information, the facility failed to provide a written plan for providing outreach services which includes identifying persons in need of project services.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Date of Plan: 12/17/2024
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#1631
Outreach Services Plan
Purpose of Outreach Services:
The purpose of the outreach services plan is to ensure that the facility provides appropriate, accessible, and effective outreach services to individuals in need of drug and alcohol treatment in the Pittsburgh area. These services are designed to engage potential clients, raise awareness of available treatment programs, and reduce barriers to care.
Identification of Persons in Need of Services:
The facility will identify individuals who may need outpatient drug and alcohol treatment services through a variety of outreach methods, including:
1. Community Outreach and Engagement:
o Collaborating with local community organizations, shelters, clinics, hospitals, and law enforcement to identify individuals in need of treatment. These partners will refer individuals who are at risk of substance abuse or currently struggling with addiction to the facility for services.
o Establishing regular communication with local healthcare providers and social service agencies to screen clients for substance use issues and refer them for appropriate treatment.
2. Targeted Outreach for High-Risk Populations:
o Special focus on high-risk groups such as individuals recently released from incarceration, homeless individuals, pregnant women, individuals with co-occurring mental health disorders, and individuals experiencing a substance use relapse.
o Engaging with schools, employers, and family services to offer early intervention and prevention education.
3. Public Awareness Campaigns:
o Conducting informational campaigns, both in-person and digitally, to raise awareness about substance abuse issues and the availability of treatment services.
o Utilizing social media, local radio, and community events to spread the word about available treatment services.
4. Screening and Assessment:
o Offering free or low-cost screenings at community events, health fairs, and partner locations to identify individuals who may benefit from outpatient treatment.
o Providing a streamlined process for individuals to self-refer or be referred by others for initial assessments.
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Plan of Correction for Deficiency in Outreach Services
Issue Identified:
The facility has been identified as lacking a comprehensive outreach strategy to identify and engage individuals in need of outpatient drug and alcohol treatment services. This has resulted in missed opportunities to serve vulnerable populations.
________________________________________
Corrective Action to Address the Deficiency
Action Plan:
1. Develop and Formalize Outreach Strategy:
o The facility will create and formalize a written outreach services strategy to identify and engage individuals in need of services.
o The outreach plan will include clear procedures for community engagement, partnerships with local organizations, targeted interventions for high-risk populations, and public education about substance use and treatment options.
2. Staffing and Responsibility Assignment:
o A dedicated Outreach Coordinator will be appointed to oversee the outreach services, including managing relationships with community partners, conducting screenings, and ensuring proper follow-up.
o Outreach activities will be documented and reported regularly to the Facility Director to ensure compliance with the plan.
3. Training and Capacity Building:
o All staff involved in outreach efforts will receive training on cultural competency, effective communication strategies, and how to engage with individuals at risk of substance use issues.
o The Outreach Coordinator will ensure that staff are regularly updated on best practices for outreach and engagement, as well as any changes in referral processes or community partnerships.
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Steps to Prevent Recurrence
Ongoing Monitoring and Evaluation:
1. Tracking and Documentation:
o The facility will develop a system for tracking outreach efforts, including the number of individuals identified, referred, and enrolled in services. This data will be reviewed monthly to assess the effectiveness of outreach activities.
o The Outreach Coordinator will ensure that all outreach efforts are documented, and referrals are followed up on to track progress.
2. Regular Review of Outreach Efforts:
o Monthly meetings with key stakeholders (Outreach Coordinator, Facility Director, community partners) will be held to review outreach efforts, assess any barriers to engagement, and develop strategies to overcome these barriers.
o The facility will conduct an annual review of its outreach strategy to ensure that it remains effective in identifying individuals in need of services.
3. Community Partnership Engagement:
o The facility will continually expand and enhance partnerships with local community organizations, healthcare providers, shelters, and law enforcement to ensure that referrals and outreach efforts are reaching a diverse population.
o Periodic outreach and networking events will be scheduled with community partners to strengthen relationships and ensure consistent collaboration.
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Date of Completion of Corrective Action
Immediate Action Completion:
- The formal outreach strategy will be developed and approved by 1/17/2025.
- The Outreach Coordinator will be appointed and begin overseeing outreach efforts by 2/17/2025.
Ongoing Process:
- The outreach tracking system will be implemented, and the first monthly review of outreach efforts will take place by 3/17/2025.
- Training for outreach staff will be completed by 3/1/2025.
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Responsible Person for Implementation
- Responsible Person: Project Director
Role: To ensure the development and implementation of the outreach strategy, including identifying individuals in need of services, coordinating with community partners, and overseeing the training of staff. The Outreach Coordinator will also be responsible for tracking and reporting outreach outcomes.
- Responsible for Oversight: CEO
Role: To monitor the implementation of the outreach strategy, review documentation, and ensure the facility complies with the outreach plan and meets regulatory requirements.
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CEO
12/17/2024
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709.84(f)(3) LICENSURE Project management services
709.84. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of administrative information, the facility failed to provide a written plan for providing outreach services which includes encouraging persons to utilize the service delivery system.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Date of Plan: 12/17/2024
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#1635
Utilization of Service Delivery System
Purpose of Outreach Services:
The utilization of service delivery plan aims to actively promote the facility's outpatient drug and alcohol treatment programs, ensuring that individuals in need of substance use treatment in Pittsburgh, PA are encouraged to utilize the facility's services. The plan outlines strategies for reaching out to potential clients, providing information about available services, and reducing barriers to care.
Encouraging Utilization of Services:
The facility will employ a range of outreach methods designed to engage individuals in the community and encourage them to access services, including:
1. Community Engagement:
o Partnering with local healthcare providers, shelters, law enforcement agencies, schools, and community organizations to raise awareness of the facility's services.
o Collaborating with these organizations to provide information about the facility's services and to facilitate referrals for individuals in need of substance abuse treatment.
2. Public Awareness Campaigns:
o Conducting community-based public service announcements, including social media campaigns, local radio advertisements, and flyers posted in high-traffic areas.
o Organizing and participating in health fairs, educational seminars, and other community events to inform the public about the importance of substance use treatment and the available services.
3. Targeted Outreach for High-Risk Populations:
o Identifying and targeting vulnerable or high-risk populations, such as individuals recently released from incarceration, those experiencing homelessness, pregnant women, and people with co-occurring mental health disorders.
o Engaging local employers, family services, and educational institutions to provide outreach and resources on substance use prevention and treatment.
4. Referral and Intake Process:
o Ensuring that the intake process is easy, accessible, and designed to reduce barriers to entry. This may include offering walk-in services, free initial assessments, and offering sliding scale fees to reduce financial barriers.
o Providing information in multiple languages and formats to ensure accessibility for all community members.
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Plan of Correction for Deficiency in Encouraging Utilization of Services
Issue Identified:
The facility has been identified as lacking an active, consistent outreach strategy aimed at encouraging individuals to utilize the facility's outpatient drug and alcohol services. This deficiency has resulted in lower-than-expected engagement from the community and a limited client base.
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Corrective Action to Address the Deficiency
Action Plan:
1. Develop a Comprehensive Outreach Strategy:
o The facility will develop and implement a formalized outreach strategy that includes specific steps to promote the facility's services within the Pittsburgh community. This strategy will include:
Detailed plans for outreach and public education.
Clear roles and responsibilities for outreach staff.
Metrics for measuring outreach success (e.g., number of referrals, increase in client engagement).
2. Hiring or Assigning an Outreach Coordinator:
o The facility will designate an Outreach Coordinator to oversee all outreach activities. This person will be responsible for developing relationships with community partners, managing public awareness campaigns, and ensuring that the referral process is streamlined.
3. Training Staff on Outreach and Engagement:
o All relevant staff will undergo training to effectively engage with individuals who may benefit from outpatient drug and alcohol treatment services.
o The training will include techniques for outreach, how to encourage participation, addressing concerns about treatment, and guiding individuals through the intake process.
4. Implement Public Awareness Campaigns:
o The facility will roll out targeted public awareness campaigns using digital and traditional media. This will include:
Social media ads and community-based digital content to spread awareness.
Radio advertisements and partnerships with local community groups to get the word out.
Distribution of materials (brochures, flyers) in high-traffic areas like hospitals, clinics, shelters, and local businesses.
5. Tracking Outreach Effectiveness:
o The facility will implement a system to track outreach efforts and monitor the number of people reached, referred, and engaged. This will allow the facility to assess the effectiveness of the outreach plan and adjust strategies as needed.
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Steps to Prevent Recurrence
Ongoing Monitoring and Evaluation:
1. Regular Outreach Evaluation:
o Monthly evaluations of the outreach efforts will be conducted by the Outreach Coordinator and reviewed by the Facility Director. These evaluations will track the success of community partnerships, the number of referrals, and client enrollment.
2. Continuous Improvement of Outreach Efforts:
o The facility will use feedback from clients, community partners, and staff to continuously improve the outreach approach. This includes adjusting strategies for engaging high-risk populations and ensuring that the services meet the evolving needs of the community.
3. Annual Review of Outreach Strategy:
o The outreach strategy will be reviewed annually to ensure it remains relevant and effective. The facility will adjust the strategy based on community feedback, the changing needs of the target populations, and new opportunities for collaboration.
4. Maintaining Community Relationships:
o The Outreach Coordinator will be responsible for maintaining ongoing relationships with community partners, ensuring that the facility remains visible and accessible within the Pittsburgh area.
o The facility will host regular networking meetings with community organizations, healthcare providers, and local authorities to keep them informed of services and encourage ongoing referrals.
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Date of Completion of Corrective Action
Immediate Action Completion:
- The Outreach Coordinator will be appointed, and the outreach strategy will be finalized and implemented by 1/17/2025.
- Initial public awareness campaigns will launch by 2/17/2025.
Ongoing Process:
- The first outreach evaluation will take place by 3/17/2025, and ongoing tracking will occur on a monthly basis.
- The annual review of the outreach strategy will be completed by 12/17/2025.
- The agency will post a list of resources on the information board in the office by 1/17/2025.
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Responsible Person for Implementation
- Responsible Person: Project Director
Role: To ensure the development and implementation of the outreach strategy, manage public awareness campaigns, and coordinate referrals. The Outreach Coordinator will also oversee the training of staff and ensure that outreach efforts are evaluated regularly.
- Responsible for Oversight: CEO
Role: To monitor and evaluate the effectiveness of the outreach plan, ensure that the strategy is being followed, and oversee regular review processes.
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CEO
12/17/2024
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709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of administrative information, the facility failed to provide a written plan for providing outreach services which includes identifying persons in need of project services.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Date of Plan: 12/17/2024
________________________________________
#1925
Outreach Services Plan (OP)
Purpose of Outreach Services:
The purpose of the outreach services plan is to ensure that the facility provides appropriate, accessible, and effective outreach services to individuals in need of drug and alcohol treatment in the Pittsburgh area. These services are designed to engage potential clients, raise awareness of available treatment programs, and reduce barriers to care.
Identification of Persons in Need of Services:
The facility will identify individuals who may need outpatient drug and alcohol treatment services through a variety of outreach methods, including:
1. Community Outreach and Engagement:
o Collaborating with local community organizations, shelters, clinics, hospitals, and law enforcement to identify individuals in need of treatment. These partners will refer individuals who are at risk of substance abuse or currently struggling with addiction to the facility for services.
o Establishing regular communication with local healthcare providers and social service agencies to screen clients for substance use issues and refer them for appropriate treatment.
2. Targeted Outreach for High-Risk Populations:
o Special focus on high-risk groups such as individuals recently released from incarceration, homeless individuals, pregnant women, individuals with co-occurring mental health disorders, and individuals experiencing a substance use relapse.
o Engaging with schools, employers, and family services to offer early intervention and prevention education.
3. Public Awareness Campaigns:
o Conducting informational campaigns, both in-person and digitally, to raise awareness about substance abuse issues and the availability of treatment services.
o Utilizing social media, local radio, and community events to spread the word about available treatment services.
4. Screening and Assessment:
o Offering free or low-cost screenings at community events, health fairs, and partner locations to identify individuals who may benefit from outpatient treatment.
o Providing a streamlined process for individuals to self-refer or be referred by others for initial assessments.
________________________________________
Plan of Correction for Deficiency in Outreach Services
Issue Identified:
The facility has been identified as lacking a comprehensive outreach strategy to identify and engage individuals in need of outpatient drug and alcohol treatment services. This has resulted in missed opportunities to serve vulnerable populations.
________________________________________
Corrective Action to Address the Deficiency
Action Plan:
1. Develop and Formalize Outreach Strategy:
o The facility will create and formalize a written outreach services strategy to identify and engage individuals in need of services.
o The outreach plan will include clear procedures for community engagement, partnerships with local organizations, targeted interventions for high-risk populations, and public education about substance use and treatment options.
2. Staffing and Responsibility Assignment:
o A dedicated Outreach Coordinator will be appointed to oversee the outreach services, including managing relationships with community partners, conducting screenings, and ensuring proper follow-up.
o Outreach activities will be documented and reported regularly to the Facility Director to ensure compliance with the plan.
3. Training and Capacity Building:
o All staff involved in outreach efforts will receive training on cultural competency, effective communication strategies, and how to engage with individuals at risk of substance use issues.
o The Outreach Coordinator will ensure that staff are regularly updated on best practices for outreach and engagement, as well as any changes in referral processes or community partnerships.
________________________________________
Steps to Prevent Recurrence
Ongoing Monitoring and Evaluation:
1. Tracking and Documentation:
o The facility will develop a system for tracking outreach efforts, including the number of individuals identified, referred, and enrolled in services. This data will be reviewed monthly to assess the effectiveness of outreach activities.
o The Outreach Coordinator will ensure that all outreach efforts are documented, and referrals are followed up on to track progress.
2. Regular Review of Outreach Efforts:
o Monthly meetings with key stakeholders (Outreach Coordinator, Facility Director, community partners) will be held to review outreach efforts, assess any barriers to engagement, and develop strategies to overcome these barriers.
o The facility will conduct an annual review of its outreach strategy to ensure that it remains effective in identifying individuals in need of services.
3. Community Partnership Engagement:
o The facility will continually expand and enhance partnerships with local community organizations, healthcare providers, shelters, and law enforcement to ensure that referrals and outreach efforts are reaching a diverse population.
o Periodic outreach and networking events will be scheduled with community partners to strengthen relationships and ensure consistent collaboration.
________________________________________
Date of Completion of Corrective Action
Immediate Action Completion:
- The formal outreach strategy will be developed and approved by 1/17/2025.
- The Outreach Coordinator will be appointed and begin overseeing outreach efforts by 2/17/2025.
Ongoing Process:
- The outreach tracking system will be implemented, and the first monthly review of outreach efforts will take place by 3/17/2025.
- Training for outreach staff will be completed by 3/1/2025.
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Responsible Person for Implementation
- Responsible Person: Project Director
Role: To ensure the development and implementation of the outreach strategy, including identifying individuals in need of services, coordinating with community partners, and overseeing the training of staff. The Outreach Coordinator will also be responsible for tracking and reporting outreach outcomes.
- Responsible for Oversight: CEO
Role: To monitor the implementation of the outreach strategy, review documentation, and ensure the facility complies with the outreach plan and meets regulatory requirements.
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CEO
12/17/2024
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709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of administrative information, the facility failed to provide a written plan for providing outreach services which includes encouraging persons to utilize the service delivery system.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Date of Plan: 12/17/2024
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#1929
Utilization of Service Delivery System (OP)
Purpose of Outreach Services:
The utilization of service delivery plan aims to actively promote the facility's outpatient drug and alcohol treatment programs, ensuring that individuals in need of substance use treatment in Pittsburgh, PA are encouraged to utilize the facility's services. The plan outlines strategies for reaching out to potential clients, providing information about available services, and reducing barriers to care.
Encouraging Utilization of Services:
The facility will employ a range of outreach methods designed to engage individuals in the community and encourage them to access services, including:
1. Community Engagement:
o Partnering with local healthcare providers, shelters, law enforcement agencies, schools, and community organizations to raise awareness of the facility's services.
o Collaborating with these organizations to provide information about the facility's services and to facilitate referrals for individuals in need of substance abuse treatment.
2. Public Awareness Campaigns:
o Conducting community-based public service announcements, including social media campaigns, local radio advertisements, and flyers posted in high-traffic areas.
o Organizing and participating in health fairs, educational seminars, and other community events to inform the public about the importance of substance use treatment and the available services.
3. Targeted Outreach for High-Risk Populations:
o Identifying and targeting vulnerable or high-risk populations, such as individuals recently released from incarceration, those experiencing homelessness, pregnant women, and people with co-occurring mental health disorders.
o Engaging local employers, family services, and educational institutions to provide outreach and resources on substance use prevention and treatment.
4. Referral and Intake Process:
o Ensuring that the intake process is easy, accessible, and designed to reduce barriers to entry. This may include offering walk-in services, free initial assessments, and offering sliding scale fees to reduce financial barriers.
o Providing information in multiple languages and formats to ensure accessibility for all community members.
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Plan of Correction for Deficiency in Encouraging Utilization of Services
Issue Identified:
The facility has been identified as lacking an active, consistent outreach strategy aimed at encouraging individuals to utilize the facility's outpatient drug and alcohol services. This deficiency has resulted in lower-than-expected engagement from the community and a limited client base.
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Corrective Action to Address the Deficiency
Action Plan:
1. Develop a Comprehensive Outreach Strategy:
o The facility will develop and implement a formalized outreach strategy that includes specific steps to promote the facility's services within the Pittsburgh community. This strategy will include:
Detailed plans for outreach and public education.
Clear roles and responsibilities for outreach staff.
Metrics for measuring outreach success (e.g., number of referrals, increase in client engagement).
2. Hiring or Assigning an Outreach Coordinator:
o The facility will designate an Outreach Coordinator to oversee all outreach activities. This person will be responsible for developing relationships with community partners, managing public awareness campaigns, and ensuring that the referral process is streamlined.
3. Training Staff on Outreach and Engagement:
o All relevant staff will undergo training to effectively engage with individuals who may benefit from outpatient drug and alcohol treatment services.
o The training will include techniques for outreach, how to encourage participation, addressing concerns about treatment, and guiding individuals through the intake process.
4. Implement Public Awareness Campaigns:
o The facility will roll out targeted public awareness campaigns using digital and traditional media. This will include:
Social media ads and community-based digital content to spread awareness.
Radio advertisements and partnerships with local community groups to get the word out.
Distribution of materials (brochures, flyers) in high-traffic areas like hospitals, clinics, shelters, and local businesses.
5. Tracking Outreach Effectiveness:
o The facility will implement a system to track outreach efforts and monitor the number of people reached, referred, and engaged. This will allow the facility to assess the effectiveness of the outreach plan and adjust strategies as needed.
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Steps to Prevent Recurrence
Ongoing Monitoring and Evaluation:
1. Regular Outreach Evaluation:
o Monthly evaluations of the outreach efforts will be conducted by the Outreach Coordinator and reviewed by the Facility Director. These evaluations will track the success of community partnerships, the number of referrals, and client enrollment.
2. Continuous Improvement of Outreach Efforts:
o The facility will use feedback from clients, community partners, and staff to continuously improve the outreach approach. This includes adjusting strategies for engaging high-risk populations and ensuring that the services meet the evolving needs of the community.
3. Annual Review of Outreach Strategy:
o The outreach strategy will be reviewed annually to ensure it remains relevant and effective. The facility will adjust the strategy based on community feedback, the changing needs of the target populations, and new opportunities for collaboration.
4. Maintaining Community Relationships:
o The Outreach Coordinator will be responsible for maintaining ongoing relationships with community partners, ensuring that the facility remains visible and accessible within the Pittsburgh area.
o The facility will host regular networking meetings with community organizations, healthcare providers, and local authorities to keep them informed of services and encourage ongoing referrals.
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Date of Completion of Corrective Action
Immediate Action Completion:
- The Outreach Coordinator will be appointed, and the outreach strategy will be finalized and implemented by 1/17/2025.
- Initial public awareness campaigns will launch by 2/17/2025.
Ongoing Process:
- The first outreach evaluation will take place by 3/17/2025, and ongoing tracking will occur on a monthly basis.
- The annual review of the outreach strategy will be completed by 12/17/2025.
- The agency will post a list of resources on the information board in the office by 1/17/2025.
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Responsible Person for Implementation
- Responsible Person: Project Director
Role: To ensure the development and implementation of the outreach strategy, manage public awareness campaigns, and coordinate referrals. The Outreach Coordinator will also oversee the training of staff and ensure that outreach efforts are evaluated regularly.
- Responsible for Oversight: CEO
Role: To monitor and evaluate the effectiveness of the outreach plan, ensure that the strategy is being followed, and oversee regular review processes.
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CEO
12/17/2024
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