INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Open Door Counseling at Mazzoni Center 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the project failed to document a written initial individual training plan for each employee, appropriate to that employee's skill level with input from both the employee and the supervisor in four out of seven records reviewed.
Employee #3 was hired on December 30, 2024, and was to have an initial individual training plan documented by January 30, 2025; however, there was no training plan documented in the personnel record until March 20, 2025.
Employee #4 was hired on January 13, 2025, and was to have an initial individual training plan documented by February 13, 2025; however, there was no training plan documented in the personnel record until March 12, 2025.
Employee #5 was hired on January 13, 2025, and was to have an initial individual training plan documented by February 13, 2025; however, there was no training plan documented in the personnel record until March 12, 2025.
Employee #6 was hired on January 13, 2025, and was to have an initial individual training plan documented by February 13, 2025; however, there was no training plan documented in the personnel record until March 12, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
To correct the deficiency regarding the absence of timely initial individual training plans for new staff, the Facility Director has developed and implemented a standardized individual training plan template, denoting the requirement that each new employee's plan is to be completed within 30 days of their start date. These plans are developed collaboratively between the employee and supervisor, as required. For the employees cited in the deficiency (Employees #3, #4, #5, and #6), completed training plans were documented in their personnel files as of March 20, 2025. Going forward, the Clinical Supervisor will conduct a 45-day audit for all newly hired employee records to verify that individual training plans are completed in the required timeframe. The Facility Director will review the results of these audits on a quarterly basis to ensure continued compliance. The facility will be in full compliance with this standard by May 30, 2025. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual written staff performance evaluation in one of seven personnel records reviewed.
Employee #2 was hired as the clinical supervisor on October 1, 2020 and was a current employee at the time of the inspections. An annual written staff performance evaluation was documented in the record on August 9, 2023, and the next annual staff performance evaluation was due no later than August 9, 2024; however, there was no annual staff performance evaluation documented in the personnel record at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the missing annual performance evaluation for Employee #2, the Clinical Supervisor completed the overdue evaluation and reviewed it with the employee as of April 3, 2025. To prevent recurrence, the HR department has implemented an annual performance evaluation alert procedure that sends out several reminders at least 30 days prior to the annual evaluation due date. The Facility Director will oversee compliance with these procedures by conducting quarterly audits of personnel records. The facility will be in full compliance with this standard by May 30, 2025. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in four of five applicable records reviewed.
Client #4 was admitted on August 10, 2023 and was discharged on August 5, 2024. An updated treatment and rehabilitation plan was documented in the record on March 11, 2024, and the next update was due no later than May 11, 2024; however, an updated treatment plan was not documented in the record until June 3, 2024.
Client #5 was admitted on April 6, 2023 and was discharged on January 31, 2025. An updated treatment and rehabilitation plan was documented in the record on June 12, 2024, and the next update was due no later than August 12, 2024; however, an updated treatment plan was not documented in the record until September 6, 2024.
Client #6 was admitted on December 27, 2023 and was discharged on August 5, 2024. An updated treatment and rehabilitation plan was documented in the record on March 18, 2024, and the next update was due no later than May 18, 2024; however, an updated treatment plan was not documented in the record until July 18, 2024.
Client #7 was admitted on January 3, 2024 and was discharged on October 29, 2024. A comprehensive treatment and rehabilitation plan was documented in the record on February 9, 2024, and the next updates were due no later than April 9, 2024; however, there were no updated treatment and rehabilitation plans documented in the client record prior to discharge.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the failure to update treatment and rehabilitation plans at least every 60 days for several clients, the Clinical Supervisor will conduct a mandatory staff training on April 17, 2025, reinforcing regulatory requirements for treatment plan timelines. The facility plans to research electronic health record (EHR)-based reminder technology to see if an automated alert system can prepare clinicians before a treatment plan update is due. In addition, the Clinical Supervisor will conduct quarterly chart audits to ensure all updates are completed on time. Any lapses in documentation will be addressed during clinical supervision sessions. The facility will be in full compliance with this standard by May 30, 2025. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in five of six applicable client records reviewed.
Client #1 was admitted on December 16, 2024 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on January 17, 2025, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the week of February 23, 2025 through March 1, 2025.
Client #2 was admitted on January 22, 2025 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on February 10, 2025, indicated that the client was to receive one individual counseling session per week; however, there was no individual counseling session documented in the client record for the week of March 2, 2025 through March 8, 2025.
Client #4 was admitted on August 10, 2023 and was discharged on August 5, 2024. An updated treatment and rehabilitation plan, documented in the client record on March 11, 2024 indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of March 31, 2024 through April 6, 2024, May 12, 2024 through May 18, 2024, May 19, 2024 through May 25, 2024, May 26, 2024 through June 1, 2024, June 16, 2024 through June 22, 2024 and July 21, 2024 through July 27, 2024.
Client #5 was admitted on April 6, 2023 and was discharged on January 31, 2025. An updated treatment and rehabilitation plan, documented in the client record on June 12, 2024 indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of August 4, 2024 through August 10, 2024, October 27, 2024 through November 2, 2024, November 24, 2024 through November 30, 2024, December 22, 2024 through December 28, 2024, December 29, 2024 through January 4, 2025 and January 12, 2025 through January 18, 2025.
Client #6 was admitted on December 27, 2023 and was discharged on August 5, 2024. An updated treatment and rehabilitation plan, documented in the client record on March 18, 2024, indicated that the client was to receive one individual counseling session per week; however, there were no individual counseling sessions documented in the client record for the weeks of March 31, 2024 through April 6, 2024 and July 21, 2024 through July 27, 2024. Additionally, there were no individual counseling sessions documented in the client record for the month of May 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the failure to deliver and document counseling services in accordance with clients' treatment plans, the Clinical Supervisor will review the caseloads of all clinicians and reinforce the requirement to deliver services at the frequency specified in each client's plan. Any missed sessions must now be documented in the client's record with an explanation and a rescheduled appointment. This standard will be reinforced during the staff retraining conducted on April 17, 2025. Weekly documentation reviews by supervisors have been instituted to monitor compliance. Clinicians will also be required to update the treatment plan if the frequency or type of counseling services change. The facility will be in full compliance with this standard by May 30, 2025. |
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 the review of client records and the project ' s policies and procedures, the project failed to document a complete client record on an individual that included follow-up information seven days after the client ' s discharge, per facility policy, in two of four applicable client records reviewed.
Client #5 was admitted on April 6, 2023 and was discharged on January 31, 2025. Per the project ' s policies and procedures, follow-up information was to be documented no later than February 7, 2025; however, the follow-up information was not documented in the record until February 28, 2025.
Client #7 was admitted on January 3, 2024 and was discharged on October 29, 2024. Per the project ' s policies and procedures, follow-up information was to be documented no later than November 7, 2024; however, the follow-up information was not documented in the record until December 11, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To correct the deficiency related to late documentation of follow-up contact post-discharge, the discharge follow-up procedure will be retrained to highlight the required follow-up deadline of 7 days after discharge. All Clinicians will be retrained on this procedure and the facility's policy during a staff meeting on April 17, 2025. The Facility Director will conduct quarterly audits of all discharged client records to confirm that follow-up documentation occurs within the required timeframe. The facility will be in full compliance with this standard by May 30, 2025. |