INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Genesis House-Bloomsburg 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met both the education and experiential qualifications for the position. Employee #2 was hired on October 25, 2021, and promoted to facility director on July 30, 2023. This employee has no documented program planning experience. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Genesis House Inc. failed to document that the facility director met both the education and experiential qualifications for the position.
Employee #2 has a master's degree in Clinical Mental Health Counseling and a Bachelor's in Sociology. She started with the agency in October of 2021 and was promoted to Lead Counselor in May of 2023. Employee was being trained under the Clinical Director of the facility at that time. Employee then was promoted to Clinical Director in July of 2023. Employee is currently training and being supervised under the current Regional Clinical Director. Employee is also signed up for Clinical Supervision Training in December of 2023 provided by the Department of Drug and Alcohol Programs. Employee continues to be monitored and supervised by the current Regional Clinical Director and will have supervision including a focus on leadership, program planning experience, and clinical supervision on an ongoing basis. Clinical Director will also be involved in and required to attend additional training through DDAP, in order to gain additional knowledge and experience to implement program planning within the next 90 days, January 2024. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR,) a review of supervisory notes and staff interviews, the facility failed to provide supervision for its counselor assistants by a full-time clinical supervisor or counselor who meets the qualifications. The Facility Director is providing supervision for the counselor assistant currently employed at this facility. Employee #2 hired on July 30, 2023, as the Facility Director and was still employed in this position at the time of the inspection. Employee #5 was hired on June 12, 2023, as a Counselor Assistant and was still employed in this position at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis house Inc. failed to provide supervision for its counselor assistants by a full-time clinical supervisor or counselor who meets the qualifications.
As of August 7, 2023, Genesis House Inc. Bloomsburg Location, acquired a Lead Counselor in the Bloomsburg office who is a full time counselor who meets the qualifications to provide supervision to the Counselor Assistant. Upon completion of probationary/training period in November of 2023, the lead counselor will be able to provide supervision of the counselor assistant.
When Employee #5 was hired, Employee #2 had previously been promoted to Lead Counselor as of May 28, 2023. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.Employee #2 was hired as the facility director on July 30, 2023 and was still acting in that position. Employee #2 was reported to have 40 hours per week devoted to the 24 clients on their caseload.The FTE counselor's caseload calculation is as follows: 24/40 = .6 (FTE); 24/.6 =40, which equals to a client counselor ratio of 40:1.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Genesis House Inc. failed to keep client/staff ratios at or below the regulation limit of 35/1.
Genesis House Inc. is working to bring Employee #2's caseload down to meet regulatory requirements at this time. Genesis House Inc. has been transitioning in the building and training 3 new employees who would be acquiring caseloads at the same times.
Employee #2 has been working to discharge clients that need to be discharged and transitioning some of her current clients to the newer staff as they are adequately trained by November 30, 2023.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents and an interview with facility staff, the project director, failed to annually update and sign a written manual delineating project policies and procedures.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to annually update and sign a written manual delineating project policies and procedures.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and ensuring that policy and procedure are up to date and in line with DDAP requirements. As policies and procedures are reviewed, updated, and changed, the Executive Director/Regional Clinical Director, will be signing off that each one and proceed annually updating and signing the written manual delineating our policies and procedures. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support services on individual treatment plans in five out of five applicable records reviewed.Client #1 was admitted on July 11, 2023, and was still active at the time of the inspection. The treatment plan was dated September 7, 2023.Client #2 was admitted on January 4, 2023, and was still active at the time of the inspection. The treatment plan was dated January 23, 2023. Client #3 was admitted on February 7, 2023, and was still active at the time of the inspection. The treatment plan was dated March 10, 2023.Client #6 was admitted on February 8, 2023 and was discharged on September 11, 2023. The treatment plan was dated February 28, 2023. Client #7 was admitted on February 15, 2023 and was discharged on May 16, 2023. The treatment plan was dated February 28, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Throughout treatment at Genesis House Inc., support services are identified and documented in the client file (i.e. biopsychosocial, relapse prevention plan, and during the initial intake assessment). Genesis House Inc., will provide a retraining to all Genesis House Inc. employees by January 31, 2024, to ensure staff are documenting supports and supportive services directly in the Treatment Plan.
The Regional Clinical Director will collaborate with the Director of Training to provide training to all clinical staff members on documentation and treatment planning.
Each facility's clinical director to ensure this training takes place during individual supervision, group supervision, and/ or staff meetings.
Each clinical director will then be responsible to collaborate with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria.
When a deficiency is identified, the Clinical Director of the facility will work with the clinician to get the appropriate information corrected in the treatment plan for the following review.
The clinician will then be responsible for making the corrections and informing the clinical director for review and approval.
The clinical director will follow up with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria.
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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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of five applicable client records reviewed.Client #2 was admitted on January 4, 2023, and was still active at the time of the inspection. A treatment plan update was completed on May 18, 2023, and the next update was due no later than July 18, 2023; however, there was no treatment plan update documented in the record until July 24, 2023. Client #3 was admitted on February 7, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on March 10, 2023, and the next update was due no later than May 10, 2023; however, there was no treatment plan update documented in the record until June 13, 2023. Client #6 was admitted on February 8, 2023, and was discharged on September 11, 2023. An updated treatment plan update was completed on April 28, 2023, and the next update was due no later than June 28, 2023; however, there was no treatment plan update documented in the record until August 8, 2023. This is a repeat ciation from the October 11, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to document treatment plan updates within the regulatory timeframe.
Genesis House, Inc. will train/retrain all new and existing clinical employees on the importance of, and regulatory expectations of treatment plan updates on or before 60 days of the initial treatment plan.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and the review of client files.
The Compliance and Program Development Coordinator will be responsible for completing chart audits throughout the month each month and will monitor treatment plan update timelines using a clinical documentation audit tool. This tool will provide clinical staff the needed information to maintain documentation compliance.
They will then share their findings with the clinical director of each facility with expectations and a time line as to when corrections in the chart need to be completed.
The clinical director will follow up with the clinicians during supervision times and/or other times planned, to address the findings with the clinician, and develop a plan to make corrections as needed and/or make improvements moving forward.
The clinician will then be responsible for making the corrections and informing the clinical director for review and approval.
The clinical director will follow up with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in six out of seven records reviewed. The facility's policy states that case consultations must be completed, at minimum, monthly.Client #1 was admitted on July 11, 2023, and was still active at the time of the inspection There was only case consultation, dated July 12, 2023, documented in the client record. Client #2 was admitted on January 4, 2023, and was still active at the time of the inspection. There was only one case consultation, January 4, 2023, documented in this client record. Client #3 was admitted on February 7, 2023, and was still active at the time of the inspection. There was only one case consultation, dated February 7, 2023, documented in this client record. Client #4 was admitted on August 23, 2023, and was still active at the time of the inspection. There was only one case consultation, dated August 29, 2023, documented in this client record. Client #6 was admitted on February 8, 2023 and was discharged on September 11, 2023.There were two, case consultations, dated February 13, 2023 and August 31, 2023, documented in this client record.Client #7 was admitted on February 15, 2023, and was discharged on May 16, 2023. There were two case consultations, dated February 15, 2023, and May 4, 2023, documented in the client record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy states that case consultations must be completed, at minimum, monthly.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and ensuring that policy and procedure are up to date and in line with DDAP requirements. As policies and procedures are reviewed, updated, and changed, the Executive Director/Regional Clinical Director, will be signing off that each one and proceed annually updating and signing the written manual delineating our policies and procedures.
The current policy on Case Consultation is currently under review/revision at this time and is projected to be completed by December 31, 2023.
Genesis House will then ensure that the new policy and procedure is distributed to all staff for training and review to be completed by January 31, 2024.
Clinical Directors will then document when completing case consultation with clinicians and keep record for review. |