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 2, an abbreviated on-site inspection, conducted on October 1, 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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Observations
Based on a review of patient records, the facility failed to provide patient # 2 with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment.
Patient # 2 was admitted on November 1, 2019 and was still active at the time of the inspection. In May 2020, the patient only had 60 minutes of psychotherapy. In July 2020, the patient only had 30 minutes of psychotherapy. In August 2020, the patient only had 40 minutes of psychotherapy and in September 2020, the patient only had 45 minutes of psychotherapy.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Provider's Plan of Corrective Action for DOH Survey Completed 10/1/2020
Regarding the deficiency noted relating to minimum therapy requirements for persons receiving medication-assisted treatment with buprenorphine described in 715.19(1), specifically the finding that one client, client #2 was not seen for 2.5 hours of therapy with at least 1 hour of individual per month during the first 2 years of medication-assisted treatment noting 60 minutes of therapy in May 2020, 0 minutes in June 2020, 30 minutes in July 2020, 40 minutes in August 2020, and 45 minutes in September 2020:
At the time of Intake 11/1/2019, client #2 a history of medication-assisted treatment (MAT) with buprenorphine for 1 year. Per the PMDR, we have record of buprenorphine prescriptions from another provider beginning 12/5/2018 and multiple attempts at therapy treatment at this facility since induction on buprenorphine in December 2018 and most recent admission on 11/1/2019 due to referral from her prescribing physician. Minimum required hours were scheduled in May 2020 (the Agency scheduled 3 hours of individual therapy for client #2 and in September the Agency scheduled 4 hours of individual therapy), however only 2 hours of individual therapy were scheduled in July and August of 2020 and 0 hours were scheduled in June 2020 (partially due to client #2 scheduled surgery).
Per the Agency's Policy and Procedure regarding Treatment Protocols for Medication-Assisted Clients effective 7/1/2012, clients within their first 2 years of MAT with buprenorphine are to be recommended and scheduled for at least 2.5 hours of therapy monthly with at least one of those hours being individual therapy. These policy and procedures were reviewed with the entire treatment staff in October (Target and Achieved date 10/31/2020). The Clinical Supervisor and Nurse Navigator will monitor therapy appointments for clients on MAT with buprenorphine at least monthly beginning 11/1/2020 and moving forward. Upon review of sessions scheduled for client #2 specifically, as of the date of this writing, 11/17/2020, client number 2 has been scheduled for 3 hours of individual therapy thus far on 11/3/2020, 11/5/2020, and 11/12/2020. She cancelled the initial appointment but attended the following two. Additionally, she is scheduled for another hour of individual therapy on 11/23/2020.
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