INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2019 of The Open Door by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form completed by the facility on May 15, 2019, the facility failed to ensure that the outpatient caseload did not exceed 35:1.
Employee #6 was hired as a counselor on July 1, 2013 and was still acting in that position. At the time of the inspection, employee #6 had a client caseload ratio of 40/1 exceeding the 35/1 ratio.
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Plan of Correction
Regarding the deficiency noted relating to 704.12(a)(6) Outpatient Caseloads in which employee #6 had a client caseload ration of 40/1, exceeding the 35/1 ratio, the Clinical Supervisor will monitor caseloads more closely via reports in the electronic medical record and routinely in individual supervision to ensure that no treatment specialist exceeds the 35/1 ratio. Implementation of this change occurred effective Monday, May 20, 2019. The Executive Director is responsible for ensuring that the corrective action plan is implemented. Completion Date: Initial correction of this deficiency was completed as of Thursday, May 23, 2019. Target date for the future is ongoing due to the nature of the regulation and procedures. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records, the facility failed to document a consent to release information form that complied with 42 CFR Part 2, 28 Pa. Code 709.28 and 4 Pa. Code 255.5 (b) in one of seven records reviewed.
Client #1 was admitted on May 13, 2019 and was an active client at the time of inspection. A consent to release information form was signed and dated on May 1, 2019 to a county probation office, however the information to be disclosed was not indicated on that release.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Regarding the deficiency noted relating to 709.28(c)(2) Confidentiality in which one release in in one chart did not reflect specifically what information was to be disclosed. The release was completed by a staff member who is no longer with the agency. Training regarding confidentiality and correct release form completion with Interns will be more rigorous and include internally created written test materials. We are in the process of developing the release form in the electronic medical record that will not allow signing or saving of the release until all required fields are completed. We are in the process of working out minor updates to this form and obtaining and activating the hardware necessary to complete this change. Until this is implemented in full, increased internal monitoring of release form completion and addressing of concerns related to findings will occur twice weekly. Implementation of this change occurred effective Monday, May 20, 2019. The Executive Director is responsible for ensuring that the corrective action plan is implemented. Completion Date: The release form has been completed and is live as of Thursday, June 13, 2019. We have obtained and been able to active some of the hardware necessary as of June 13, 2019. Full completion is projected to occur by August 1, 2019. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
It was determined that on May 15, 2019 that the facility was over their capacity of 271 in oupatient as their current census was 273.
These findings were reviwed with facility staff during the licensing process
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Plan of Correction
Regarding the deficiency noted relating to 704.14(b)(5) Subchapter B. Licensing Procedures. Restriction. in which it was determined that the facility was over its outpatient capacity by 2 persons. The Clinical Supervisor will monitor caseloads more closely in individual supervision to ensure that cases that are appropriate for discharge are done so in a timely manner, as well as increased monitoring of census by report through the electronic medical record to ensure that we are operating within our capacity. Implementation of this change occurred effective Monday, May 20, 2019. The Executive Director is responsible for ensuring that the corrective action plan is implemented. Completion Date: Initial correction of this deficiency was completed as of Thursday, May 23, 2019. Target date for the future is ongoing due to the nature of the regulation and procedures. |