INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 2021 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(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 the review of personnel records, the facility failed to ensure that staff persons received the required of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment, in one of two personnel records.
Employee # 4 was hired as a counselor on January 7, 2019. The trainings were to be completed by January 7, 2020. There was no documentation provided that the training had been completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will schedule the 6 HIV/AIDS training and the 4 hour tuberculosis, sexually transmitted diseases and other health related topics training in collaboration with the HR Manager by March 15,2021. Both the 6 and 4 hour trainings will be held as soon as possible, no later than April 30, 2021. The staff who are overdue for the training will attend no later than April 30, 2021. The HR Manager will ensure that both the 6 HIV/AIDS training and the 4 hour tuberculosis, sexually transmitted diseases and other health related topics training are scheduled twice per year in order to ensure continued compliance with the requirements. The HR Manager will also ensure that documentation of attendance at trainings is maintained in the personnel records. |
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 the review of client records, the facility failed to obtain an informed and voluntary consent form for the disclosure of information contained in the client record, in seven of seven client records.
Releases for the third party payer were documented in client records # 1, 2, 3, 4, 5, 6 and 7. The releases had not been signed by the client. Releases documented "telehealth" or "client verbally agreed " in the client signature line. Correspondence was released to the third-party payer without a valid release.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical Supervisor will train all staff on the requirement and procedure to obtain signatures with clients who prefer to meet via telehealth as of 3/30/2021.
During the training, all clinical staff will be reminded that information cannot be disclosed without a signed informed and voluntary consent form for the disclosure of information. All clinical staff will be informed that as of 3/31/2021, releases will no longer be documented "telehealth" or "client verbally agreed" in the client signature line. All consent to release information forms must contain a client signature.
One of four methods to obtain the signature will be acceptable: 1. use of Electronic Health Record (EHR) to send forms via the secure EHR and allow clients to sign 2. email the form to client and client email a signed form back to counselor with a witness of their choice 3. Use USPS to mail the form for client signature with a witness of their choice and return with a postage paid envelope 4. Client to come into the clinic to sign forms with counselor, Clinical Director or Clinical Supervisor as witness.
The Clinical Director and Clinical Supervisor will ensure that all client records include an informed and voluntary consent form for the disclosure of information signed by the client by conducting monthly chart audits. |
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 the review of client records, the facility failed to obtain an informed and voluntary consent form, signed by the client, for the disclosure of information contained in the client's record in seven of seven client records.
Releases documented in client records # 1, 2, 3, 4, 5, 6 and 7 had not been signed by the client. Releases documented "telehealth" or "client verbally agreed " in the client signature line.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical Supervisor will train all staff on the requirement and procedure to obtain signatures with clients who prefer to meet via telehealth as of 3/30/2021.
During the training, all clinical staff will be reminded that information cannot be disclosed without a signed informed and voluntary consent form for the disclosure of information. All clinical staff will be informed that as of 3/31/2021, releases will no longer be documented "telehealth" or "client verbally agreed" in the client signature line. All consent to release information forms must contain a client signature.
One of four methods to obtain the signature will be acceptable: 1. use of Electronic Health Record (EHR) to send forms via the secure EHR and allow clients to sign 2. email the form to client and client email a signed form back to counselor with a witness of their choice 3. Use USPS to mail the form for client signature with a witness of their choice and return with a postage paid envelope 4. Client to come into the clinic to sign forms with counselor, Clinical Director or Clinical Supervisor as witness.
The Clinical Director and Clinical Supervisor will ensure that all client records include an informed and voluntary consent form for the disclosure of information signed by the client by conducting monthly chart audits. |
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 the review of client records, the facility failed to document that treatment plans were reviewed and updated at least every 60 days, in three of seven client records.
Client # 3 had an update due to be completed by November 4, 2020. There was no documentation that the update had been completed. An update due to be completed by January 4, 2021 was completed on January 22, 2021.
Client # 5 had updates due to be completed by September 1 and November 1, 2020. There was no documentation that the updates had been completed.
Client # 7 had an update due to be completed by June 8, 2020. There was no documentation that the update had been completed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director trained all clinical staff on the importance of documenting that treatment plans were reviewed and updated at least every 60 days on February 23, 2021. The
Clinical Supervisor will monitor compliance with documenting that treatment plans were reviewed and updated at least every 60 days during weekly chart audits with counselors in supervision sessions on an ongoing basis beginning on the week of March 1, 2021. The administrative assistant will send treatment plan update reminder messages on the computer system to the staff and will train the staff on how to set up a reminder on or before March 31, 2021. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in three of four client records.
Per agency policy, follow- up is to be completed within 7 days of discharge.
Client # 5 was discharged on December 3, 2020. There was no documentation of follow-up information.
Client # 6 was discharged on October 15, 2020. There was no documentation of follow-up information.
Client # 7 was discharged on October 7, 2020. There was no documentation of follow-up information.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
All staff were trained on the agency policy that follow- up is to be completed within 7 days of discharge on February 23, 2021 via a meeting. The Clinical Director and Clinical Supervisor will ensure that follow ups are conducted within 7 days of discharge by conducting monthly clinical chart audits and alerting staff to upcoming follow-up due dates using the computer system on an ongoing basis. |