INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23-24, 2026, 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 Pathways 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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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 an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records.
Client #6 was admitted on May 16, 2025, and discharged November 18, 2025. There was no release of information for the funder in the record. The facility confirmed billing had occurred.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 4, 2025, licensing inspection.
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Plan of Correction
The Project Director will require all staff to attend a confidentiality refresher training during the April 24, 2026 meeting. All assigned counselors will obtain missing consent to release information to funders on any active record by May 1, 2026. The Project Director and Clinical Supervisor will conduct monthly random chart reviews to ensure compliance with documentation standards as of May 1, 2026. Any staff member who is still missing consent to release information to funders in their records as of May 1, 2026 will be required to re-take the online confidentiality training offered by DDAP.
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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 six applicable records.
Client #5 was admitted on August 14, 2025, and discharged on January 22, 2026. A treatment plan was developed on September 19, 2025, and an update was due no later than November 19, 2025; however, there were no updates in the record.
Client #6 was admitted on May 16, 2025, and discharged on November 18, 2025. A treatment plan was developed on May 28, 2025, and an update was due no later than July 28, 2025; however, there were no updates in the record.
Client #7 was admitted on June 17, 2025, and discharged on December 15, 2025. A treatment plan was developed on July 1, 2025, and an update was due no later than September 1, 2025; however, it was completed September 9, 2025. The next update was due no later than November 9, 2025; however, there were no further updates in the record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 13, 2024, and March 4, 2025, licensing inspections.
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Plan of Correction
The Project Director will coach the team regarding treatment plan updates at each scheduled monthly staff meeting for the next year beginning on April 24, 2026. The Project Director will have the treatment plan update date added to the monthly case consultation form in order to highlight the date in advance to both the assigned counselor and Clinical Supervisor by May 15, 2026. The Clinical Supervisor and Project Coordinator will conduct monthly record reviews to ensure compliance with the treatment plan update policy as of May 1, 2026. |
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 was submitted and approved by the Department for the March 13, 2024, and March 4, 2025, annual licensing inspections. Treatment plan updates was again found to be a deficiency in the March 23-24, 2026 licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A quality record review report will be issued to the Project Director monthly as of May 1, 20206. The Clinical Supervisor will compile the quality record review report monthly as of May 1, 20206. This will allow the Project Director to ensure compliance with treatment plan updates on a consistent basis as of May 1, 2026. |