INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14-15, 2016 by staff from the Division of Drug and Alcohol 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to provide exits from the nonresidential facility that were unobstructed.
The findings include:
A physical plant inspection was conducted on March 15, 2016. An exit door in the counselors wing that opened to the outside was stuck and staff were not able to open the door at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Outside In, notified landlord about fire exit door not opening. Landlord fixed door on March 16, 2016. Facility Director verified that fire exit door is opening properly and will continue to ensure at monthly fire drills. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plan and treatment plan updates for medical assistance clients within the timeframe's established by the Office of Medical Assistance in two of four client records.
The findings included:
Ten client records were reviewed on March 14-15, 2016. Four of the client records were required to have a physician signature on the individual treatment plan and updates. The individual treatment plan and/or updates contained in client records # 6 and #8 did not contain a physician signature within the timeframe's established by the Office of Medical Assistance.
Client # 6 was admitted to outpatient treatment on November 12, 2015 and discharged on February 23, 2016 . The individual treatment and rehabilitation plan updates completed on December 1, 2015 and January 29, 2016 did not include a physician's signature.
Client # 8 was admitted to outpatient treatment on July 28, 2015 and discharged on January 22, 2016. The individual treatment and rehabilitation plan, completed on July 28, 2015 and updates completed on October 4, 2015 and December 4, 2015 did not include a physician's signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director has developed a checklist on March 16,2016 for supervisor to ensure and verify all treatment plans and updates are being reviewed and signed by the physician for all medical assistance clients. The clinical supervisor will review with the counselor's the procedures for physician review and signature of treatment plans. The clinical supervisor will ensure and verify that all treatment plans and updates will be reviewed and signed by the physician in all medical assistance records. All records from March 16, 2016 will have treatment plans signed by the physician. |