INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on August 29-30, 2019, and September 3, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection and complaint investigation, Open Arms Recovery Center 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the facility ' s policies and procedures conducted during the on-site inspection and complaint investigation, the facility failed to follow the plan adopted by the governing for the coordination of client treatment and rehabilitation services in two client records reviewed.
The facility ' s policies and procedures manual indicates that client intakes will be completed on the first session, and that the comprehensive/individualized treatment plan will be completed within 30 days of the intake.
Client #1 ' s intake was completed on May 15, 2019, but the client ' s individualized treatment plan was not completed until July 10, 2019.
Client #3 ' s intake was completed on May 13, 2019, but the client ' s individualized treatment plan was not completed until June 20, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Our new Clinical Supervisor will review treatment planning with all clinical staff during supervision and team meetings. Clinical Supervisor will monitor treatment plans weekly along with clinical staff to ensure due dates are met. Clinical Staff will complete an individualized Master Treatment plan at the third session and review it with the Clinical Supervisor before the thirty day due date. The facility will be in full compliance by 11/1/2019. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review client records conducted during the on-site inspection and complaint investigation, the facility failed to ensure that its consents to release information from client records did not exceed the restriction in 4PA code 255.5. 4PA code 255. 5 restricts the information that facilities can release to funding sources and the criminal justice system. 4PA code 255.5b reads,
" (b) Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. "
The consent to release information to Client #1 ' s health insurance company, dated April 25, 2019, authorizes the release of the client ' s biopsychosocical evaluations, treatment plans, treatment plan updates, psychiatric evaluations, psychological evaluations, blood tests, urinalysis and physical examinations.
The consent to release information to Client #5 ' s health insurance company, dated July 8, 2019, authorizes the release of the client ' s biopsychosocical evaluations, treatment plans, treatment plan updates, psychiatric evaluations, psychological evaluations, blood tests, urinalysis and physical examinations.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Clinical Supervisor and Facility Director developed updated Releases of Information one of which that only allows the five specific things to be checked off on the release. They are as follows;(1)Whether the client is or is not in treatment, (2)The prognosis of the client, (3) The nature of the project, (4)A brief description of the progress of the client, and (5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. The second Release of Information will be utilized for groups that are not restricted by 4 Pa. Code 255.5 such as other treatment providers, family members, and the client's Primary Care Physician. Clinical Staff and front office staff will begin this change immediately. Clinical Supervisor, Director of Operations, and Facility Director will train all staff on the correct updated releases. Facility will be in full compliance immediately. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection conducted on August 28, 2019, the facility failed to store client records in locked storage containers.
During the physical plant inspection there were archived paper files for clients stored in a locked room, but the files were in card board boxes and not locked containers.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Director of Operations will purchase locked containers to store past paper charts in. The files are currently locked in a file room that has one available key that the Director of Operations only has access to. The facility will be in compliance with this deficiency by 10/14/2019. |
709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review client records conducted during the on-site inspection and complaint investigation, the facility failed to ensure that its consents to release information from client records were signed and dated by the clients and the witnesses on the same day.
The consent to release information to Client #6 ' s health insurance company had a dated signature from the client of July 31, 2019, but the witness ' s signature was dated June 4, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Director of Operations, Facility Director, and Clinical Supervisor have re-trained front office staff on ensuring that when the ROI is prepared to not sign until after the client has signed. Clinical Supervisor will ensure ROI's are in compliance during weekly supervision with Clinicians.This facility will be in compliance immediately. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection conducted on August 29, 2019, and staff interviews conducted September 3, 2019, there was no hot water under pressure in the two bathrooms located in suite 3 of the facility.
On August 29, 2019, the hot water was tested in all the bathrooms in the facility, and the bathrooms in suite 3 did not have hot water. On September 3, 2019, the staff of the facility stated that the building maintenance checked the hot water heater for the two bathrooms in suite 3, and they said that there was no hot water in suite 3 when it was tested because the heating element in the hot water heater for suite 3 was defective.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
On August 30, 2019, while the inspector was present, the heating element was fixed and hot water was working again. To ensure this does not occur again, maintenance will check water temperatures monthly. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records conducted during the onsite inspection and complaint investigation, the facility failed to ensure that it informed female patients of the possible risks of buprenorphine treatment on unborn children.
Patient #7 was admitted for outpatient treatment on October 1, 2018, began buprenorphine treatment on October 8, 2018, and was discharged from treatment on April 22, 2019, but there was no documentation that the patient was informed about the dangers of buprenorphine on unborn children.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Clinical Supervisor, Director of Operations, and Facility Director have changed the wording on the already created document on Illicit Drug Use and dangers of Illicit Drug use during pregnancy to the unborn child to, Dangers of Buprenorphine and illicit drug use during pregnancy. Members are also educated in group and individual sessions on the dangers of illicit drug use and Buprenorphine to the unborn child by Facility Director. Our Medical Director whom is an Obstetrician also comes to group sessions to inform pregnant individuals of the dangers of Buprenorphine and Illicit Drug Use. Clinical Supervisor also updated informed consent with stated information. Facility Director sent a copy of updated document to DDAP. Facility will be in full compliance 10/4/19. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of client records conducted during the on-site inspection and complaint investigation, the facility failed to ensure that patients receiving treatment with a narcotic agent received the required monthly psychotherapy hours.
Patient #6 was admitted for narcotic treatment on November 30, 2017, and as a patient with less than 2 years in narcotic treatment was required to have at least 2.5 hours of psychotherapy every month.
The patient only received 1 hour a month of psychotherapy in March and April of the year 2019, and 0 hours a month in June and July of the year 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Clinical Supervisor and Facility Director updated our informed consent to reflect the required hours up to 4 years. Clinicians will have an aftercare Suboxone group session at 1.5 hours per month, and a one hour individual session per month for Suboxone clients. To ensure clients are receiving the average of 2.5 hours a month of psychotherapy, our Clinical Supervisor will review charts with Clinicians in weekly supervision. This facility will be in compliance 11/01/2019. |
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 conducted during the on-site inspection and complaint investigation, the facility failed to ensure that all treatment plans were updated at least once every 60 days in 1 of 2 applicable client records reviewed.
A total of 7 client records were reviewed during the on-site inspection, and 2 records reviewed required treatment plan updates.
Client #6 had a treatment plan update completed on April 24, 2019, but the client ' s treatment plan was not updated again until July 31, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Clinical Supervisor will review all of each Clinician's charts and treatment plans to ensure that Master Treatment Plans and Treatment Plan Updates are completed by the required due dates. All Clinicians will develop an Excel Sheet to keep track of all Master Treatment Plan
required due dates and Treatment Plan Updates. During Treatment Team Meeting on 10/2/19 Clinical Supervisor trained staff on this plan of correction. This facility will be in full compliance by 11/1/19. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of staff records and staff interviews conducted during the on-site inspection and complaint investigation, the facility failed to ensure that all its counselors had the required education and experience to be counselors at the facility.
Staff Person #4 was hired as an Associate Degree level counselor on September 25, 2018. As an Associate Degree level counselor the staff person was required to have 2 years of clinical experience to be a counselor, but the staff person only had 9 months of clinical experience prior to being hired.
Staff Person #5 was promoted from a counselor assistant to an Associate Degree level counselor on April 5, 2018, based on the number of college credits the staff person had earned. As an Associate Degree level counselor the staff person was required to have an Associate Degree, but at the time the staff person was promoted and at the time of the on-site inspection and complaint investigation, the staff person did not have a documented Associate Degree.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Staff Person #5 at the time was enrolled in an bachelor degree program where he earned his 60 credits and had achieved the required hours as clinical experience in which he was promoted ,however after the promotion the school closed creating an inability to obtain documentation stating Staff Person #5 had an associates degree equivalency. At the time of inspection unofficial transcripts were produced to show Staff Person #5 does indeed have 60 credits. At the time of inspection Staff Person #5 had not yet enrolled into another bachelor program, due to his previous college closing. However, at this time Staff Person #5 is enrolled in a Bachelors program, which Staff Person #5 began on 10/01/19. Per the department of education an official transcript is the only documentation available to clarify that Staff Person #5 has an equivalency of an Associates Degree since the school is now closed. Staff Person #5 in fact has 100/120 credits to complete his Bachelor's degree. At this time Staff Person #5 possess an official sealed transcript which clarifies Staff Person #5 has surpassed the amount of credits needed for an Associates degree equivalency, but does not have the degree due to doing a Bachelor's Program, not an Associates Program. An individual enrolled in a Bachelor's Program does not receive an Associates Degree, but an equivalency to an Associates Degree. Staff Person #5 will be promoted to Counselor status upon completing the Bachelor Program.
Staff Person #4 had 9 months experience in a clinical setting at a previous employer, and currently has obtained 12 additional months clinical experience at Open Arms Recovery Center for a total of 21 months, therefore Staff Person #4 will have 3 more months close supervision and be promoted to counselor. Clinical Supervisor will conduct the close supervision for both Staff Person #4 & #5. Staff person #4 is currently enrolled in a Bachelors Program. All supervision has been sent and reviewed by DDAP.
To ensure that this does not occur in the future Clinical Supervisor, Facility Director, and the Director of Operations will discuss hours of supervision with DDAP and send resume's to ensure for approval before hiring clinicians.
This facility will be in compliance immediately. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff records conducted during the on-site inspection and complaint investigation, the facility failed to ensure that all its staff had the mandatory training in communicable diseases within the required time frames.
Staff Person #3 was hired as a counselor on September 5, 2017. The staff person was required to have 6 hours of HIV/AIDS training and 4 hour of TB/STD training by September 5, 2018, but at the time of the on-site inspection and complaint investigation the staff person had no documentation of training in these areas.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
As of 9/27/19, staff person #3 will no longer be employed at Open Arms Recovery Center. To ensure this does not occur in the future, training plans will be reviewed by Clinical Supervisor monthly. Facility Director will follow up with Clinical Supervisor during supervision to ensure training hours are being met. This facility will be in full compliance effective immediately. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff records conducted during the on-site inspection and complaint investigation, the facility failed to ensure that all its staff had the required training hours for the previous training year.
The facility ' s training years begins and ends on its fiscal year. The previous training year began on July 1, 2018, and it ended June 30, 2019.
Staff Person #2, a counselor, was required to have 25 hours of training during the previous training year, but only had 18 hours of documented training for the previous training year.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Clinical Supervisor will review training plans monthly to ensure training hours are being met. Facility Director will follow up with Clinical Supervisor to ensure training hours are being met. This facility will be in full compliance immediately.
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