INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on May 2, 2019. Based on the findings of the on-site inspection, Outside In Pathway To Recovery Outpatient Services was found to not be in compliance with the applicable chapters of 28 PA Code whichpertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
During a review of client records on May 2, 2019, the facility failed to document client medical histories in four out of seven records. Client # 3 was admitted on August 6, 2018 and was discharged on August 21, 2018. There was no medical history documented for client #3. Client #4 was admitted on December 28, 2018 and was discharged on January 28, 2019. There was no medical history documented for client #4. Client # 6 was admitted on January 1, 2019 and was discharged on January 28, 2019. There was no medical history documented for client #6. Client #7 was admitted on January 3, 2019 and was discharged on January 17, 2019. There was no medical history documented for client #7. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to address the deficiency found in section 709.91(b)(3)(i), Outside In will more clearly specify the time frames associated with the intake process in our policies and procedures. This section denotes that medical histories are included in the intake process; however, the Project considers the time-frame within which the intake procedures are completed in their entirety to span the first three sessions of the treatment episode. The medical history is contained within the larger Biopsychosocial Assessment, which is completed by the third session. In the case of Clients 3, 4, 6, and 7, there were only two sessions completed prior to discharge, so the intake process had not been completed. This specific time frame for the completion of the Biopsychosocial Assessment was found to be absent from the policies and procedures. The following plan of correction will address this deficiency:
- Facility Director will amend the policies and procedures manual to indicate that the intake process is completed over the course of three sessions. Specifically, the first session with a client will allow for the completion of criteria for admission; treatment methodology; requirements for the completion of treatment; involuntary discharge/termination criteria; documentation of disclosure of criteria for admission, treatment, completion, and discharge; client orientation (including project policies, hours of operation, fee schedule, and services provided); consent to treatment; and the preliminary treatment and rehabilitation plan. Beginning in the first session and spanning through the second and third sessions, the comprehensive Biopsychosocial Assessment will be completed. This document will include, but not be limited to, medical history, drug and/or alcohol history, personal history, and psychosocial evaluation. Physical exam has been ruled to be inapplicable in the outpatient component of our Project. This edit to the policies and procedures will be completed no later than June 30, 2019.
- Clinical Supervisor will monitor client records at least monthly to ensure that the intake process and related documentation is being completed per the time frames specified above. These reviews will begin in the month of June, 2019, subsequent to the edits being made to the policies and procedures. Facility Director, Clinical Supervisor, and Counselors will also meet quarterly to complete a thorough peer review of selected client records. This peer review process will partly be targeting the timely completion of intake/admission documentation. The next peer review of client records is scheduled for June of 2019. If the Clinical Supervisor finds that intake documentation is not being completed in a timely manner, it will result in verbal or written coaching, formal disciplinary supervision, and/or further disciplinary action for the clinician failing to follow procedures.
- Facility Director will meet with Clinical Supervisor for consultation and supervision on a monthly basis, and will include check-ins regarding this plan of correction to ensure compliance. The incorporation of this plan of correction into these meetings will also begin in June of 2019. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
During a review of client records on May 2, 2019, the facility failed to document client drug and/or alcohol histories in four out of seven records. Client # 3 was admitted on August 6, 2018 and was discharged on August 21, 2018. There was no drug and/or alcohol history documented for client #3. Client #4 was admitted on December 28, 2018 and was discharged on January 28, 2019. There was no drug and/or alcohol history documented for client #4. Client # 6 was admitted on January 1, 2019 and was discharged on January 28, 2019. There was no drug and/or alcohol history documented for client #6. Client #7 was admitted on January 3, 2019 and was discharged on January 17, 2019. There was no drug and/or alcohol history documented for client #7. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to address the deficiency found in section 709.91(b)(3)(ii), Outside In will more clearly specify the time frames associated with the intake process in our policies and procedures. This section denotes that drug and/or alcohol histories are included in the intake process; however, the Project considers the time frame within which the intake procedures are completed in their entirety to span the first three sessions of the treatment episode. The drug and/or alcohol history is contained within the larger Biopsychosocial Assessment, which is completed by the third session. In the case of Clients 3, 4, 6, and 7, there were only two sessions completed prior to discharge, so the intake process had not been completed. This specific time frame for the completion of the Biopsychosocial Assessment was found to be absent from the policies and procedures. The following plan of correction will address this deficiency:
- Facility Director will amend the policies and procedures manual to indicate that the intake process is completed over the course of three sessions. Specifically, the first session with a client will allow for the completion of criteria for admission; treatment methodology; requirements for the completion of treatment; involuntary discharge/termination criteria; documentation of disclosure of criteria for admission, treatment, completion, and discharge; client orientation (including project policies, hours of operation, fee schedule, and services provided); consent to treatment; and the preliminary treatment and rehabilitation plan. Beginning in the first session and spanning through the second and third sessions, the comprehensive Biopsychosocial Assessment will be completed. This document will include, but not be limited to, medical history, drug and/or alcohol history, personal history, and psychosocial evaluation. Physical exam has been ruled to be inapplicable in the outpatient component of our Project. This edit to the policies and procedures will be completed no later than June 30, 2019.
- Clinical Supervisor will monitor client records at least monthly to ensure that the intake process and related documentation is being completed per the time frames specified above. These reviews will begin in the month of June, 2019, subsequent to the edits being made to the policies and procedures. Facility Director, Clinical Supervisor, and Counselors will also meet quarterly to complete a thorough peer review of selected client records. This peer review process will partly be targeting the timely completion of intake/admission documentation. The next peer review of client records is scheduled for June of 2019. If the Clinical Supervisor finds that intake documentation is not being completed in a timely manner, it will result in verbal or written coaching, formal disciplinary supervision, and/or further disciplinary action for the clinician failing to follow procedures.
- Facility Director will meet with Clinical Supervisor for consultation and supervision on a monthly basis, and will include check-ins regarding this plan of correction to ensure compliance. The incorporation of this plan of correction into these meetings will also begin in June of 2019. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
During a review of client records on May 2, 2019, the facility failed to document client personal histories in four out of seven records. Client # 3 was admitted on August 6, 2018 and was discharged on August 21, 2018. There was no personal history documented for client #3. Client # 6 was admitted on January 1, 2019 and was discharged on January 28, 2019. There was no personal history documented for client #6. Client #7 was admitted on January 3, 2019 and was discharged on January 17, 2019. There was no personal history documented for client #7. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to address the deficiency found in section 709.91(b)(3)(iii), Outside In will more clearly specify the time frames associated with the intake process in our policies and procedures. This section denotes that personal histories are included in the intake process; however, the Project considers the time frame within which the intake procedures are completed in their entirety to span the first three sessions of the treatment episode. The personal history is contained within the larger Biopsychosocial Assessment, which is completed by the third session. In the case of Clients 3, 6, and 7, there were only two sessions completed prior to discharge, so the intake process had not been completed. This specific time frame for the completion of the Biopsychosocial Assessment was found to be absent from the policies and procedures. The following plan of correction will address this deficiency:
- Facility Director will amend the policies and procedures manual to indicate that the intake process is completed over the course of three sessions. Specifically, the first session with a client will allow for the completion of criteria for admission; treatment methodology; requirements for the completion of treatment; involuntary discharge/termination criteria; documentation of disclosure of criteria for admission, treatment, completion, and discharge; client orientation (including project policies, hours of operation, fee schedule, and services provided); consent to treatment; and the preliminary treatment and rehabilitation plan. Beginning in the first session and spanning through the second and third sessions, the comprehensive Biopsychosocial Assessment will be completed. This document will include, but not be limited to, medical history, drug and/or alcohol history, personal history, and psychosocial evaluation. Physical exam has been ruled to be inapplicable in the outpatient component of our Project. This edit to the policies and procedures will be completed no later than June 30, 2019.
- Clinical Supervisor will monitor client records at least monthly to ensure that the intake process and related documentation is being completed per the time frames specified above. These reviews will begin in the month of June, 2019, subsequent to the edits being made to the policies and procedures. Facility Director, Clinical Supervisor, and Counselors will also meet quarterly to complete a thorough peer review of selected client records. This peer review process will partly be targeting the timely completion of intake/admission documentation. The next peer review of client records is scheduled for June of 2019. If the Clinical Supervisor finds that intake documentation is not being completed in a timely manner, it will result in verbal or written coaching, formal disciplinary supervision, and/or further disciplinary action for the clinician failing to follow procedures.
- Facility Director will meet with Clinical Supervisor for consultation and supervision on a monthly basis, and will include check-ins regarding this plan of correction to ensure compliance. The incorporation of this plan of correction into these meetings will also begin in June of 2019. |
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
During a review of records on May 2, 2019, the facility failed to document psychosocial evaluations in four out of seven records. Client # 3 was admitted on August 6, 2018 and was discharged on August 21, 2018. There was no psychosocial evaluation documented for client #3. Client #4 was admitted on December 28, 2018 and was discharged on January 28, 2019. There was no psychosocial evaluation documented for client #4. Client # 6 was admitted on January 1, 2019 and was discharged on January 28, 2019. There was no psychosocial evaluation documented for client #6. Client #7 was admitted on January 3, 2019 and was discharged on January 17, 2019. There was no psychosocial evaluation documented for client #7. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to address the deficiency found in section 709.91(b)(6), Outside In will more clearly specify the time frames associated with the intake process in our policies and procedures. This section denotes that psychosocial evaluations are included in the intake process; however, the Project considers the time frame within which the intake procedures are completed in their entirety to span the first three sessions of the treatment episode. The psychosocial evaluation is contained within the larger Biopsychosocial Assessment, which is completed by the third session. In the case of Clients 3, 4, 6, and 7, there were only two sessions completed prior to discharge, so the intake process had not been completed. This specific time frame for the completion of the Biopsychosocial Assessment was found to be absent from the policies and procedures. The following plan of correction will address this deficiency:
- Facility Director will amend the policies and procedures manual to indicate that the intake process is completed over the course of three sessions. Specifically, the first session with a client will allow for the completion of criteria for admission; treatment methodology; requirements for the completion of treatment; involuntary discharge/termination criteria; documentation of disclosure of criteria for admission, treatment, completion, and discharge; client orientation (including project policies, hours of operation, fee schedule, and services provided); consent to treatment; and the preliminary treatment and rehabilitation plan. Beginning in the first session and spanning through the second and third sessions, the comprehensive Biopsychosocial Assessment will be completed. This document will include, but not be limited to, medical history, drug and/or alcohol history, personal history, and psychosocial evaluation. Physical exam has been ruled to be inapplicable in the outpatient component of our Project. This edit to the policies and procedures will be completed no later than June 30, 2019.
- Clinical Supervisor will monitor client records at least monthly to ensure that the intake process and related documentation is being completed per the time frames specified above. These reviews will begin in the month of June, 2019, subsequent to the edits being made to the policies and procedures. Facility Director, Clinical Supervisor, and Counselors will also meet quarterly to complete a thorough peer review of selected client records. This peer review process will partly be targeting the timely completion of intake/admission documentation. The next peer review of client records is scheduled for June of 2019. If the Clinical Supervisor finds that intake documentation is not being completed in a timely manner, it will result in verbal or written coaching, formal disciplinary supervision, and/or further disciplinary action for the clinician failing to follow procedures.
- Facility Director will meet with Clinical Supervisor for consultation and supervision on a monthly basis, and will include check-ins regarding this plan of correction to ensure compliance. The incorporation of this plan of correction into these meetings will also begin in June of 2019. |