INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2021 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 eight personnel records reviewed, the facility failed to ensure the qualifications for the position of a counselor to include at least one year of experience for employee # 3.
Employee # 3 was hired as a counselor on March 29, 2021 and was still in this position at the time of the inspection. Based off of employee # 3's resume and previous job description, employee # 3 did not have at least one year of clinical experience with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of hire, employee #3 had documented 7 years of experience as a Counselor/Advocate III at another agency. The position itself lists counselor in the title and the employee had listed on her resume and described verbally in interview individual and group counseling as part of her experience in this position. Upon obtainment of employee #3's official job description during the licensing process, these duties were not spelled out as part of the job description. As such, this experience was found to be insufficient to meet the one-year experience criteria. Effective the date of licensing review on 6/15/2021, employee #3 has been re-designated as a Counselor Assistant. Please note that this employee has been receiving supervisory oversight, close supervision, consistent with that of a Counselor Assistant since employment start date as part of our usual process with new employees. Moving forward, the Clinical Supervisor and Executive Director will ensure obtainment of official job descriptions to determine appropriate position assignment for new hires when there is a question about type of experience in light of this review. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on one of sixteen employee records reviewed, the facility failed to ensure Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS within the regulatory timeframe of one year for counselors.
Employee # 4 was hired a counselor on June 5, 2019 and was still in this position at the time of the inspection. As of the inspection date, employee # 4 had not received 6 hours of HIV/AIDS training which was due no later than June 5, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 was scheduled for DDAP approved HIV/AIDS 6-hour course on 3/4/2020 and 4/7/2020. Both of these trainings were cancelled. Further offerings were not available to our knowledge for an extended period of time during the pandemic. Employee #4 has since attempted to enroll in recent and near future offerings of this training. She is waiting for registration to open to schedule this training for 8/10/2021 and 8/11/2021. Should DDAP specific required trainings be cancelled in the future, the agency will contact DDAP directly to advise regarding other trainings that would be sufficient to meet the training requirement or request a waiver for an extension on the time frame for training completion. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, The facility failed to provide a sufficient number of staff persons certified in CPR training onsite during the facility's hours of operation. All facility personnel had CPR certifications that were expired.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Four full-time staff had active CPR certifications through March 13th, 2021, however we have been out of compliance since this date. Three full time staff members were recertified as of July 2, 2021. All remaining staff will complete CPR recertification by 7/19/2021. Additionally, we are pursuing having two staff members trained to be CPR Instructors so we will have instructors on staff to provide this training on-site as needed. |
709.28 (c) 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.
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Observations
Based on two of seven client records reviewed, the facility failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 3 was admitted on August 13, 2020 and discharged on October 20, 2020. A fax was sent to a transportation company without an informed and voluntary consent from the client for the disclosure of information.
Client # 7 was admitted on August 12, 2020 and discharged on January 7, 2021. A fax was sent to second county probation office that provided discharged information without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the instance of client #3 in which a fax was sent to a transportation company, the client and therapist completed an application for medical assistance transportation together via telehealth as the client could not obtain transportation to attend onsite services. The application was faxed to the transportation program from our agency at the request of the client. The clinician did fail to obtain formal documentation of consent via completion of an authorization for the release of information form. The clinician who provided the service and failed to complete formal consent documentation is no longer with the agency. The noted concern identified with this citation regarding client #3 as well as client #7 described below and the requirement of obtaining written informed consent for information release was reviewed with all current clinical staff on 6/17/2021.
In the case of client #7 in which a fax was sent to a second county probation office that provided discharged information without a consent for information. The circumstances leading to this release of information were investigated. A verbal warning was given and factors contributing to this error as well as different actions to take in the future to prevent this from occurring again were addressed in individual supervision with the clinician making the error on 7/1/2021. Further infractions of this nature will result in further disciplinary action.
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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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 4 was admitted on September 17, 2020 and was discharged on January 28, 2021. An informed and voluntary consent from the client for the disclosure of information to community agency did not provide the information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the case of client #4, a release of information was completed for a community agency but the clinician completing the form failed to complete the section indicating what information was to be disclosed. Additionally, while there was also on file a fully completed release of information form (including what information was to be disclosed) from the agency in question, the language on the other agency's release of information form regarding this facility's ability to release information to the agency was found to be insufficient to allow the release to be acted upon. As this agency's form was incomplete and the other agency's form insufficient, the release of information should not have occurred. As such, in addition to the requirement of obtaining informed consent from clients for the release of information, elements required, and language needed to make release valid were reviewed with all clinical staff on 6/17/2021. The clinician who failed to indicate what information was to be disclosed was an intern at the time and no longer with the agency to review concerns with. Closer monitoring by the Clinical Supervisor of releases (both those completed by this facility's staff and those received from other entities) will occur to ensure only fully complete and valid releases are acted upon. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on six of seven applicable client records reviewed, the facility failed to provide a complete comprehensive treatment and rehabilitation plan to include the type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on November 23, 2020 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed with the client on December 7, 2020 did not provide the type and frequency of treatment services.
Client # 3 was admitted on August 13, 2020 and was discharged on October 20, 2020. The comprehensive treatment and rehabilitation plan developed with the client on September 8, 2020 did not provide the type and frequency of treatment services.
Client # 4 was admitted on September 17, 2020 and was discharged on January 28, 2021. The comprehensive treatment and rehabilitation plan developed with the client on September 27, 2020 did not provide the type and frequency of treatment services.
Client # 5 was admitted on November 5, 2020 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed with the client on December 21, 2020 did not provide the type and frequency of treatment services.
Client # 6 was admitted on March 9, 2021 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed with the client on March 26, 2021 did not provide the type and frequency of treatment services.
Client # 7 was admitted on August 12, 2020 and was discharged on January 7, 2021. The comprehensive treatment and rehabilitation plan developed with the client on August 26, 2020 did not provide the type and frequency of treatment services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of charts #2, #3, #4, #5, #6, and #7 it was found that while type of service is consistently referred to in other places in the chart it is inconsistently referred to in Comprehensive Treatment Plans or not spelled out clearly. Frequency of service was found to be absent in Comprehensive Treatment Plans. Of the five clinicians responsible for the above cases two are no longer with the agency to address concerns with individually. Specific concerns were addressed to the other three clinicians in individual supervision on the following dates: 6/16/2021, 7/6/2021, and 7/7/2021. The requirement of documenting type and frequency of services was reviewed with all current staff across two dates: 6/24/2021 and 6/28/2021. Closer monitoring by the Clinical Supervisor of Comprehensive Treatment Plans to ensure that type and frequency of service are included in all treatment plans will occur until this pattern is resolved. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on four of four applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information according to the facility policy and procedure manual of thirty days after discharge and documented in the client record.
Client # 3 was admitted on August 13, 2020 and discharged on October 20, 2020. There was no follow-up information documented in the client record.
Client # 4 was admitted on September 17, 2020 and discharged on January 28, 2021. There was no follow-up information documented in the client record.
Client # 7 was admitted on August 12, 2020 and discharged on January 7, 2021. There was no follow-up information documented in the client record.
Client # 8 was admitted on October 9, 2020 and discharged on November 3, 2020. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of charts #3, #4, #7 and #8 and further investigation, it was discovered that there was a time period during the pandemic in which follow-up calls were not occurring and circumstances leading to this. A new system for identifying, completing and tracking follow-up calls was developed and implemented on 6/22/2021 addressing factors contributing to this lapse, streamlining the procedure, and streamlining tracking of completion. |