INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 2022 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 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of twelve employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 4.
Employee # 4 was hired as a counselor assistant on July 6, 2021 and promoted to a counselor position on January 6, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 4's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 15, 2021 annual licensing inspection.
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Plan of Correction
Regarding the deficiency noted relating to 704.7(b)(3) in which employee #4 was promoted to a Counselor position following 6 months of employment as a Counselor Assistant and did not meet criteria for a Counselor position at that time. The initial classification of Counselor Assistant was correct, however the employee was promoted 6 months too soon. This error was made due to a misunderstanding of how or whether 704.9(c)(2) relating to the supervised period for a bachelor's level Counselor Assistant impacted promotion of a Counselor Assistant to a Counselor as defined in regulation 704.10 relating to Promotion of a Counselor Assistant. Following clarification of this with the Executive Director and Clinical Supervisor with licensing inspector, employee #4 will be reclassified as a Counselor Assistant effective 5/11/2022 and will not be repromoted to a full Counselor position until she has obtained 1 year of clinical experience as of 7/6/2022. The Executive Director advised the Human Resources Supervisor of regulation clarification. The Clinical Supervisor and Human Resources Supervisor will track and monitor this moving forward.
Additionally, the Please note that it was indicated that this was a repeat citation. Previous citation was due to initial hire of an employee as a Counselor instead of a Counselor Assistant. Upon review by the licensing inspector during the 6/15/2021 inspection, it was determined by the inspector that the employee's 7 years of experience as a Counselor/Advocate did not meet criteria for clinical experience. As such, following the inspection, the employee had been reclassified as a Counselor Assistant and has since obtained 1 year of clinical experience.
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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 one of one applicable employee personnel record reviewed, the facility failed to provide documentation of six months supervision to also include one hour of direct observation for a counselor assistant with a bachelor ' s degree for employee # 12.
Employee # 12 was hired as a counselor assistant on January 3, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 12's personal record documentation of six months supervision did not include notes of the supervision provided and for the weeks of February 20-26, March 6-12, 13-19, 20-26, 27-April 2, April 3-9, 10-16, 17-23, and 24-30 did not include one hour of direct observation with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding deficiency noted relating to 704.9(c)(2) in which it was noted that employee #12 did not have documentation of supervision provided and that documentation of direct observation was missing for 9 weeks. Direct observation of employee #12 has occurred at least weekly, however, specific mention of this in documentation was absent in 9 of the weeks since hire. Documentation of weekly supervision for employee #12 signed by Clinical Supervisor and employee #12 was on file at the agency and provided to licensing inspector, however, upon review of this documentation by inspector, it was determined that it was not sufficiently detailed to indicate that clinical supervision occurred. Following discussion and clarification with the Executive Director and Clinical Supervisor, the Executive Director and Clinical Supervisor discussed on 5/11/2022, specifically with employee #12 the need for more detail in documentation of supervision notes and those notes were to include documentation of direct observation experienced, and further in a meeting with the treatment team the need for detail in supervision notes. Clinical Supervisor will monitor this more closely moving forward effective 5/11/2022. New supervision forms with specific prompts to help improve supervision documentation will be created and implemented by 7/1/2022. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of January 2021 through December 2021, the facility failed to provide documentation of a fire drill being conducted the months November and December 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the deficiency related to 705.28(d)(1) in which it was noted that fire safety drills were not completed in November and December of 2021. The previous Executive Director did not conduct drills during these months and other members of the management team did not complete due to significant and overlapping periods of quarantines related to the pandemic and other medical leave as well as periods of time off due to the holidays in these months. The new Executive Director documented lack of drills in the the fire log. The new Executive Director as of the first of the year has conducted fire drills monthly since this time and reviewed fire drill conduction procedures with all members of the management team in January 2022 and new managers hired will be instructed in fire drill conduction procedures. Additionally, a Medical Records and Facilities Coordinator position was created. This person will be responsible for tracking compliance, maintaining documentation on fire drills, and will further be trained in fire drill conduction. This position will be filled 6/1/2022. The Executive Director and Chief Compliance Officer will be responsible for ensuring compliance until this time. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill log for the months of January 2021 through December 2021, the facility failed to maintain a written fire drill record including documentation of any problems encountered during the fire drill for the months of July 2021 through January 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the deficiency related to 705.28(d)(4) in which it was noted that fire drill records in 2021 did not include a component addressing if any problems occurred during the fire drill. The Fire Drill Record Form completed by previous Executive Director was a long-time established form. The current Executive Director was employed in another capacity at the time of the 2021 fire safety drills and can note that no problems occurred during fire drills conducted however, a statement to this affect was not specifically noted on the Fire Drill Form. The incoming Executive Director created a new Fire Drill Safety Form first used on 1/5/2022 that does specifically have a section requiring a yes or no response if there were any problems to note and a space for explanation if problems were present. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had "Telehealth signature" on the signature line.
Client # 6 was admitted on December 15, 2021 and was discharged February 11, 2022. An informed and voluntary consent from the client for the disclosure of information dated December 2, 2021 to a funding agency, county agency, PCP, lab, treatment facility, and emergency contact did not have a valid signature by the client but instead had "Telehealth signature" on the signature line.
Client # 7 was admitted on January 19, 2022 and was discharged March 21, 2022. An informed and voluntary consent from the client for the disclosure of information dated December 2, 2021 to two funding agencies, probation, county agency, lab, and emergency contact did not have a valid signature by the client but instead had "Telehealth signature" on the signature line.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding deficiency noted relating to 709.28(c)(4) relating to Confidentiality in which it was noted that in client charts #6 and #7, disclosures were made for both clients on 12/2/2021 based on releases that were signed as "Telehealth Signature". In both cases, assessments were completed via telehealth and all consents and releases of information reviewed and agreed to verbally via this modality. We have been exploring other options for medical records since the Fall and began the implementation process for a new medical record with a client portal that will have the capability to send documents and obtain electronic signatures. The tentative live date for this record is 7/1/2022. Additionally, we have reviewed other software and recently purchased a program that will allow us to obtain electronic signatures for releases of information when a client is unable to attend in person. In the meantime, effective 5/23/2022, releases of information without either a physical or electronic signature will not be acted upon until a physical or electronic signature can be obtained. Front-desk and treatment staff will be responsible for following these procedures and the Clinical Supervisor and Chief Compliance Officer will be responsible for monitoring compliance with procedures. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on two of six applicable client records reviewed, the facility failed to complete a comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicates a comprehensive treatment and rehabilitation plan be developed within 30 days of admission. Also, three of six applicable client records reviewed did not provide documentation of the comprehensive treatment and rehabilitation plan being developed with the client.
Client # 2 was admitted on August 30, 2021 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed on August 27, 2021 however, there was no documentation the comprehensive treatment and rehabilitation plan was developed with the client.
Client # 3 was admitted on November 15, 2021 and was still active at the time of inspection. A comprehensive treatment and rehabilitation plan was due no later than December 15, 2021 however, was not completed until January 13, 2022. Also, there was no documentation the comprehensive treatment and rehabilitation plan was developed with the client.
Client # 4 was admitted on March 28, 2022 and was still active at the time of inspection. A comprehensive treatment and rehabilitation plan was due no later than April 28, 2022 however, was not completed until May 8, 2022. Also, there was no documentation the comprehensive treatment and rehabilitation plan was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding deficiency noted relating to 709.92(a) in which it was noted that Comprehensive Treatment Plans were in two cases not completed timely and in 3 cases not reviewed with the client. Regarding client #2 whose treatment plan was completed timely on 8/27/2021, there is documentation that the client's goals were discussed in the group setting but it does not mention specifically that the Comprehensive Treatment Plan was reviewed with the client. Regarding client #3, whose treatment plan was completed on 1/13/2022 but due on 12/15/2021, the originally assigned therapist did not complete the Comprehensive Treatment Plan with the client, the clinician is no longer with the agency, and the client stopped attending services for nearly a month following the clinician's last day (11/30/2021) with the agency. The client did re-engage with a new to the agency, newly assigned therapist on 12/22/2021 and the newly assigned clinician completed the treatment plan albeit late and did not document review of the treatment plan with client in the client file. Regarding client #4, the assigned clinician completed the Comprehensive Treatment Plan but it was untimely and did not specifically document review of the treatment plan with the client. The Executive Director and the Clinical Supervisor discussed the review of Comprehensive Treatment Plans with clients in general with the treatment team on 5/11/2022 and need for timeliness. The Clinical Supervisor will address timeliness and need to specifically document review of the plan with the client in individual supervision with the specific therapists assigned to the above-mentioned cases by 5/31/2022. The Clinical Supervisor and Chief Compliance Officer will be responsible for monitoring timeliness of completion and review of treatment plans moving forward. |