INITIAL COMMENTS
|
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:
|
Plan of Correction
|
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.
|
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 seven records.
Client #4 was admitted on May 4, 2023 and discharged on September 16, 2023. The treatment plan was dated May 18, 2023.
Client #5 was admitted on July 20, 2023 and discharged on December 10, 2023. The treatment plan was dated August 3, 2023.
Client #6 was admitted on September 28, 2023 and discharged on December 21, 2023.
The treatment plan was dated October 12, 2023.
These findings were reviewed with the facility staff during the licensing process.
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in three of seven records.
Client #1 was admitted on June 15, 2023 and was still active at the time of the inspection.
A treatment plan update was completed on December 14, 2023 and the next update was due no later than February 14, 2024; however, the next update was completed on February 29, 2024.
Client #3 was admitted on September 7, 2023 and was still active at the time of the inspection.
A treatment plan update was completed on November 24, 2023 and the next update was due no later than January 24, 2024; however, the next update was not completed at the time of the inspection.
Client #5 was admitted on July 20, 2023 and discharged on December 10, 2023. A treatment plan update was completed on August 3, 2023 and the next update was due no later than October 3, 2023; however, it was completed October 12, 2023.
These findings were reviewed with the facility staff during the licensing process.
|
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. |