INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on April 23, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Open Door of Indiana, Pennsylvania 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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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, the facility failed to ensure that staff members received a minimum of 4 hours of tuberculosis, sexually transmitted diseases and other health related topics in one of six applicable records. Staff #6 was hired to the position of counselor on April 4, 2025 and was in this position at the time of review. Staff # 6 was due to complete 4 hours of TB/STD training no later than April 4, 2026. However, staff #6 had not completed 4 hours of TB/STD training as of the time of review.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The TB/STD training will now be offered in-house, effective immediately. The CEO is certified to conduct this training, and all staff have been notified via email. Employees requiring this training are asked to contact her directly to arrange a convenient time. This training will be provided to all new staff on an ongoing basis. |
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 review and update treatment and rehabilitation plans at least every sixty days in four of six applicable records. Client #2 was admitted to the outpatient level of care on October 27, 2025 and was active at the time of review. Client #2 had a treatment plan completed February 1, 2026. The next update was due no later than April 2, 2026. The next treatment plan update for client #2 was completed April 21, 2026.Client #3 was admitted to the outpatient level of care on December 2, 2025 and was active at the time of review. Client #3 had a treatment plan completed January 27, 2026. The next update was due no later than March 27, 2026. No further updates were found in the client record.Client #4 was admitted to the outpatient level of care on July 1, 2025 and was discharged January 6, 2026. Client #4 had a treatment plan completed on September 22, 2025. The next update was due no later than November 22, 2025. The next treatment plan update for client #4 was completed December 9, 2025.Client #5 was admitted to the outpatient level of care on October 29, 2025 and was discharged February 23, 2026. Client #5 had a treatment plan completed on December 4, 2025. The next update was due no later than February 4, 2026. The next treatment plan update for client #5 was completed February 18, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical documentation for Treatment Plan Reviews will be managed through the organization's new electronic health record (EHR) system, which generates alerts for time-sensitive documentation. The Clinical Supervisor will monitor these alerts and ensure that all required documentation is completed promptly. Clinical staff have been reminded that Treatment Plan Reviews are due every 60 days and have received guidance on utilizing the EHR alert feature, with instructions to address all alerts in a timely manner. Full compliance with this plan of correction is expected to be achieved by 5/20/2026. |