INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 28, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records and discussion with facility staff, the facility failed to ensure that employee #4 hired as a counselor assistant with a high school diploma on January 27, 2020, received direct observation for the first three months of employment. Counselor Assistant has received weekly supervision since hire.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Regarding the deficiency noted relating to qualifications and supervision of Counselor Assistant in 704.8 and 704.9, specifically the finding of employee #4, hired as a counselor assistant with a high school diploma on January 27th, 2020, received weekly direct supervision but did not operate under direct observation for the first three months of employment:
At the time of hire, employee #4 had a high school diploma, a bachelor's degree in art and a minor in art therapy and had completed the majority of courses and half of her practicum for a master's degree in art therapy. This facility provided close supervision without direct observation for the first three months ending on 4/27/2020 in error as, per review of the PA Code, it was determined that the employee's educational experience at the time of hire did not meet criteria for a Counselor Assistant with a bachelor's degree. At the time of Part 1 of the inspection, employee #4 had obtained an appropriate master's degree in compliance with the PA Code governing staffing regulations for Drug and Alcohol Treatment Facilities. This degree was conferred on 5/9/2020. A copy of employee #4's master's degree diploma as well as the transcripts from the educational program are in the employee's personnel file. As such, compliance with 704.8 and 704.9 was achieved on 5/9/2020.
The Clinical Supervisor and Executive Director have re-reviewed the PA Code governing staffing regulations and discussed the codes identified above to assure clarity with the inspecting auditor on the date of exit of Part 1 of the inspection (Target and Achieved date 5/28/2020). Additionally, target date ongoing, this facility will be diligent in adhering to Drug and Alcohol Treatment Staffing regulations as described in codes 704.8 and 704.9 in determining and providing the appropriate and required observational and supervision experiences for hires of Counselor Assistants moving forward.
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