INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Open Door 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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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly, in two of two client records reviewed in the partial hospitalization activity.
The findings include:
Six client records were reviewed on March 24, 2015. Two client records were reviewed as partial hospitalization activity. Two of two records were required to document individual counseling at least twice weekly. Client records # 3 and # 4 did not document individual counseling at least twice weekly.
Client # 3 was admitted on August 6, 2014 and discharged on November 24, 2014. There were zero (0) individual counseling sessions documented for the weeks of September 15-19, September 22-26, October 6-10, October 13-17, October 20-24 and November 10, 2014.
There was 1 individual counseling session documented for the week of September 29-October 3, 2014.
Client # 4 was admitted on December 23, 2014. There were zero (0) individual counseling sessions documented for the weeks of January 12-16, February 2-6, February 16-20 and March 8-14, 2015.
There was 1 individual counseling session documented for the weeks of January 19-23, February 9-13, February 23-27 and March 1-7 and March 15-21, 2015
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the deficiency noted in provision of Partial Hospitalization Program services relating to 709.82 (d) (1), specifically that individual counseling was not provided at least twice weekly to clients enrolled in this service. The Clinical Supervisor and Utilization Review / Auditor will monitor Partial Hospitalization Program attendance patterns more closely and intervene to ensure specifically that twice weekly hour-long individual sessions are occurring and that every effort is made to reschedule clients within the week when a client cancels or no-shows a session. Additionally, staff will be re-educated on the importance of addressing attendance with clients and making appropriate referrals should attendance of individual sessions not improve. Re-education will occur immediately. Implementation of closer monitoring practices conducted by the Utilization Review/Auditor and the Clinical Supervisor will begin immediately. The Executive Director is responsible for ensuring the corrective action plan is implemented. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to document verification of the individuals identity, including name, address, date of birth and other identifying data. in two of two patient records.
The findings include:
A total of six patient records were reviewed on March 25, 2015. Two patient records were reviewed for compliance in the Buprenorphine exception and were required to document verification of the individuals identity. Two patient records did not include the documentation.
Patient record # 1 was admitted on August 13, 2014 and was discharged on November 15, 2014. There was no documentation verifying the individual's identity, including name, address, date of birth and other identifying data.
Patient record # 2 was admitted on September 30, 2014. There was no documentation verifying the individual's identity, including name, address, date of birth and other identifying data.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the deficiency noted specifically relating to 715.9(a)(2) Intake lack of (a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall: (a) Verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data, procedures will be drafted and subsequently implemented immediately for the collection of a copy of client photo identification, or in the absence of a photo identification card, collection of one or more documents that provide verification of required data. A photo copy of this documentation will be kept on file. These procedures will be established immediately. The Executive Director is responsible for ensuring the corrective action plan is implemented. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of patient records, the facility failed to document an onsite photograph of each patient which includes the patient's name and birth date in two of two patient records.
The findings include:
A total of six patient records were reviewed on March 25, 2015. Two patient records were reviewed for compliance with the Buprenorphine exception, and were required to maintain onsite a photograph of each patient. Two patient records did not include the documentation.
Patient record # 1 was admitted on August 13, 2014 and was discharged on November 15, 2014. There was no documentation of an onsite photograph of the patient.
Patient record # 2 was admitted on September 30, 2014. There was no documentation of an onsite photograph of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the deficiency noted relating to 715.13(b) Patient identification; specifically (b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient's name and birth date. The narcotic treatment program shall update the photograph every 3 years; procedures will be drafted and subsequently implemented immediately for the collection of a copy of client photo identification. In the absence of photo identification, agency staff will take a photograph of the client with their name and birth date on site and maintain in the file. This will be updated every three years should the client maintain in the program for this length of time either by acquiring a photo copy of a renewed photo identification card or taking a new photograph of the client with their name and date of birth. These procedures will be established immediately. The Executive Director is responsible for ensuring the corrective action plan is implemented. |