INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 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 School of Experimental 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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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
Based on the review of client records, the facility failed to document a psychosocial evaluation in four of seven applicable records.
The facility ' s policy and procedure manual states the psychosocial evaluation must be completed by the third session.
Clients #1, #5, #6, and #7 did not have a psychosocial evaluation in their client records.
Client #1 was admitted on October 12, 2023 and was still active at the time of the inspection.
Client #5 was admitted on June 13, 2023 and discharged on February 6, 2024.
Client #6 was admitted on May 2, 2023 and discharged on July 1, 2023.
Client #7 was admitted on May 2, 2023 and discharged on February 13, 2024.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 28, 2023 annual licensing inspection.
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Plan of Correction
Staff will be reminded of the due date for the psychosocial evaluation at the April 12, 2024 staff meeting. The Clinical Supervisor and Project Director will monitor client records monthly to ensure that the psychosocial evaluations are completed by the third session starting on April 15, 2024. |
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 three of six applicable records.
Client #1 was admitted on October 12, 2023 and was still active at the time of the inspection.
The treatment plan was dated October 31, 2023.
Client #2 was admitted on October 26, 2023 and was still active at the time of the inspection. The treatment plan was dated December 15, 2023.
Client #3 was admitted on December 19, 2023 and was still active at the time of the inspection. The treatment plan was dated February 20, 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 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 four applicable records.
Client #1 was admitted on October 12, 2023 and was still active at the time of the inspection.
A treatment plan update was completed on January 2, 2024 and the next update was due no later than March 2, 2024; however, the next update was not completed at the time of the inspection.
Client #7 was admitted on May 2, 2023 and discharged on February 13, 2024.
A treatment plan update was completed on October 18, 2023 and the next update was due no later than December 18, 2023; however, it was not completed prior to discharge.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 28, 2023, March 16, 2022, and February 12, 2021 annual licensing inspections.
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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)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in six of seven records.
The facility's policy and procedure manual states a case consultation must be completed monthly.
Client #2 was admitted on October 26, 2023 and was still active at the time of the inspection. There were no case consultations documented in November 2023 and January 2024.
Client #3 was admitted on December 19, 2023 and was still active at the time of the inspection. There was no case consultation documented in January 2024.
Client #4 was admitted on June 7, 2023 and was discharged September 27, 2023. There was no case consultation documented in July 2023.
Client #5 was admitted on June 13, 2023 and discharged on February 6, 2024. There were no case consultations documented in July 2023 and October 2023.
Client #6 was admitted on May 2, 2023 and discharged on July 1, 2023. There were no case consultations documented in June 2023.
Client #7 was admitted on May 2, 2023 and discharged on February 13, 2024.
There were no case consultations documented in June 2023, September 2023, October 2023, November 2023, and January 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The staff will be reminded of the monthly case consultation requirement at the April 12, 2024 staff meeting. The Project Director and Clinical Supervisor will utilize random monthly audits to ensure that client records are in compliance with this requirement. |
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 two of three 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 #5 and #6.
Client #5 was admitted on June 13, 2023 and discharged on February 6, 2024.
Client #6 was admitted on May 2, 2023 and discharged on July 1, 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. |
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 were submitted and approved by the Department for the March 28, 2023, March 16, 2022, and February 12, 2021 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the March 11, 2024 annual licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 28, 2023 annual licensing inspection.
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Plan of Correction
Failure to follow the plan of correction is related to staff training and retention. The facility has two counselors who were hired around the time of the inspection. The previous counselors who were trained during the past year had resigned before this year's inspection. Staff turnover led to the failure to follow the plan of correction. In an effort to address the plan of correction this year, the Clinical Supervisor and Project Director will meet with the new counselors weekly to review deadlines for treatment plan updates. Current staff will participate in training during the April 12, 2024 staff meeting with the Clinical Supervisor and Project Director regarding how to manage treatment plan update requirements. Current staff will be instructed to complete treatment plan updates every 45 days in order to ensure completion in a timely manner during the April 12, 2024 staff meeting. This area will be monitored in monthly chart reviews and reported to agency leadership for the next 12 months. |