INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 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, Outside In Pathway 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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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in five of seven records.Client #2 was admitted on November 2, 2023 and was still active at the time of the inspection. The treatment plan was dated Novmeber 29, 2023.Client #3 was admitted on December 15, 2023 and was still active at the time of the inspection. The treatment plan was dated January 2, 2024.Client #4 was admitted on June 27, 2023 and discharged on September 5, 2023. The treatment plan was dated July 26, 2023.Client #6 was admitted on November 8, 2023 and discharged on February 9, 2024. The treatment plan was dated November 17, 2023. Client #7 was admitted on May 24, 2023 and discharged on August 11, 2023. The treatment plan was dated June 21, 2023. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will provide training regarding proposed type of support service on individual treatment plans during the April 12, 2024 staff meeting. The proposed supportive service(s) must be noted on the client's individual treatment plan. The Clinical Supervisor will utilize random monthly chart audits to ensure adherence to this requirement. The Clinical Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors. |
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 two of five applicable records.Client #1 was admitted on June 29, 2023 and was still active at the time of the inspection. A treatment plan update was completed on October 26, 2023 and the next update was due no later than December 26, 2023; however, the next update was completed on January 2, 2024. Client #6 was admitted on November 8, 2023 and discharged on February 9, 2024. A treatment plan update was completed on November 17, 2023 and the next update was due no later than January 17, 2024; however, it was completed February 5, 2024.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will provide training regarding the frequency and timeframes for treatment plan review and updates during the staff meeting on April 12, 2024. The Clinical Supervisor will conduct random monthly chart audits to ensure adherence to this requirement. The Clinical Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors. |
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 a review of client records, the facility failed to document follow-up information in three of four discharged records.The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 30 days.There was no follow up information documented in client records #4, #6, and #7.Client #4 was admitted on June 27, 2023 and discharged on September 5, 2023.Client #6 was admitted on November 8, 2023 and discharged on February 9, 2024.Client #7 was admitted on May 24, 2023 and discharged on August 11, 2023. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will provide training regarding follow up policy and procedure during the April 12, 2024 staff meeting. The follow up call must be made within 30 days of discharge. The Clinical Supervisor will utilize random monthly chart audits to ensure adherence to this requirement. The Clinical Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors. |