INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on December 28, 2008.
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Plan of Correction
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709.23(b)(2) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(2) Written reports of project operations.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document current board meeting minutes.
The finding include:
A review of the facility's policy and procedure manual and an interview conducted on December 3, 2008 with the Project Director confirmed that the facility could not produce current board of director meeting minutes for the last 12 months.
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Plan of Correction
Project director reviewed the standard with the governing body on 12/8/08 during the weekly director's meeting to ensure their understanding. Governing body agreed to provide the project director with appropriate board meeting minutes for all subsequent board meetings on 12/8/08. Project director will place the board meeting minutes in the facility's policy and procedures manual for the department's review upon receipt. Project director will monitor to ensure compliance by 12/31/08. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedure on client confidentiality and a review of the facility's HIPAA Right to Privacy Notice, the facility failed to include correct reference to 4 Pa. Code Subsection 255.5. The information provided in the HIPAA Right to Privacy Notice misinformed clients receiving drug and alcohol treatment services of their rights and protections regarding the confidentiality of any information which would identify them as a participant in drug and alcohol treatment services.
The findings include:
A thorough review of the facility's confidentiality policy and procedure regarding client records on December 2-3, 2008, revealed that the policy and procedure did not include reference to 4 Pa. Code Subsections 255.5 (a)(1) through 255.5 (c) as required.
The facility's HIPAA Right to Privacy Notice failed to inform clients that releases without client consent permitted under the HIPAA regulations may still be prohibited by state law and regulation and by federal regulation at 42 CFR Part 2. The HIPAA Right to Privacy Notice did not include any disclaimer for drug and alcohol treatment records.
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Plan of Correction
Project director will revise the facility's current confidentiality policy on 12/15/08 to address the correct reference to PA Code Subsection 255.5. Project director will secure governing body approval for the revised policy and add to the facility's policy and procedures manual by 1/5/09. Facility director will review the revised policy with the facility staff on 1/7/09 to ensure their understanding. Project director met with the governing body on 12/8/08 to address the issue of the Hipaa privacy notice. Project director will create a confidentiality form on 12/15/08 and submit for board approval by 1/5/09. The new confidentialiy form will address the disclaimer relating to the state and federal confidentiality laws and the Hipaa form. Facility director will review the new confidentiality form with the facility staff on 1/7/09 to ensure their understanding. The new form will be provided to the facility's clients in conjunction with the Hipaa notice and each will be placed in the client files. Facility director will monitor on a weekly basis during weekly chart reviews by 1/31/09 to ensure appropriate compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of documentation in agency manuals, a discussion with the Facility Director and a physical plant inspection, the facility failed to document that fire alarms are set off during each fire drill or that an alternative procedure had been approved by the Division.
The findings include:
During the review of administrative materials and a discussion with the Facility and Project Directors on December 4, 2008 it was determined that the fire alarms cannot be activated during the fire drills due to the impact on other businesses in the office complex and no documentation was on file to indicate that the Division had approved an alternative procedure.
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Plan of Correction
Project director submitted a request for an alternative procedure to the facility's fire alarm/evacuation process along with a statement that the fire system was properly inspected within the appropriate time frames to the department for approval on 12/5/08. Facility director will continue to monitor the facility's fire drill/evacuation processes on a monthly basis and document accordingly to ensure appropriate compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of 7 client records, the facility did not document complete drug and alcohol histories in five of seven records reviewed.
The findings include:
Seven client records were reviewed on December 4, 2008. All were required to have complete, detailed Drug and Alcohol histories. Client records # 1, 2, 3, 4, 5 ( 5 of 7 applicable records) contained Drug and Alcohol histories which failed to document lengths and patterns of drug and alcohol usage.
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Plan of Correction
Project director will retrain all facility staff on the appropriate completion of the facility's health questionnaire and biopsychosocial assessment forms, focusing on the documentation of the client's length and patterns of substance consumption during the facility's weekly staff meeting on 12/19/08. Facility director will monitor weekly during the clinical chart reviews by 12/31/08 to ensure appropriate compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records , the facility failed to document complete psychosocial evaluations in three of six client records.
The findings include:
Seven client records were reviewed on December 6, 2008. Six of seven records were required to have complete psychosocial evaluations. Three of six client records, # 1, 2, 3, did not include complete evaluations. There was no documentation of a psychosocial evaluation in client record #1. The psychosocial evaluations in client records # 2 and 3 did not include the counselors' evaluations of how the collected historical information was used to identify possible relationships, conditions and/or causes leading to the clients need for treatment.
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Plan of Correction
Project director will retrain the facility staff on the appropriate completion of the facility's biopsychosocial assessments, focusing on the time frames for completion and the thoroughness of the counselor's evaluative comments during the weekly staff meeting on 12/19/08. Facility director will monitor during weekly client chart reviews by 12/31/08 to ensure appropriate compliance. |
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 the review of client records, the facility failed to document a comprehensive treatment plan in one of three client records.
The findings include:
Seven client records were reviewed on December 4, 2008. Three client records were required to have comprehensive treatment plans documented. There was no documentation of a treatment plan in client record # 6.
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Plan of Correction
Project director will retrain all facility staff on the appropriate completion of the facility's treatment planning processes on 12/19/08. Facility director will monitor weekly during client chart reviews by 12/31/08 to ensure appropriate compliance. |
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 the review of seven client records, the facility failed to document complete treatment plans on each client.
The findings include:
Seven client records were reviewed on December 4, 2008. Three of the records were required to include documentation of complete treatment plans. There was no documentation of a treatment plan in client record # 6. The proposed type of support services for the client was not documented on the treatment plan in client record # 3.
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Plan of Correction
Project director will retrain all facility staff on the appropriate completion of the facility's treatment planning processes, focusing on the timeliness of completion and the documentation of support services utilized during the weekly staff meeting on 12/19/08. Facility director will monitor weekly during the client chart reviews by 12/31/08 to ensure appropriate compliance. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary in one of one client record.
The findings include:
Seven client records were reviewed on December 4, 2008. One client record was required to include documentation of a discharge summary. There was no documentation of a discharge summary in client record # 4.
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Plan of Correction
Project director will retrain all facility staff on the appropriate and timely completion of the facility's discharge summary form during the weekly staff meeting on 12/19/08. Facility director will monitor weekly during client chart reviews by 12/31/08 to ensure compliance. |