INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis House, Inc. (Williamsport) 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the January 2013 - December 2013 fire drill logs was conducted on January 22, 2014. During the months of January 2013 through and including November 2013, the facility failed to use alternate exit routes. The exit route used for the drills during that timeframe was the front door only. The exit route used for the fire drill in December 2013 utilized the front and back door.
The Facility Director did not dispute the findings.
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Plan of Correction
The Clinial Director will contine to complete the fire drill's monthly. The Director of OP services will send the Clinical Director a request of what offices the fire drill should be pulled from and what exit she should use by the first of every month. The Clinical Director will continue to log the fire drills. The Director will alternate exits and locations each month.
The Director of OP Services will check the fire drill log quarterly, to ensure that the Clinical Director is logging the fire drills properly. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in two of five personnel records reviewed.
The findings include:
Five personnel records were reviewed on January 22, 2014. Staff work performance evaluations were required in four personnel records. The facility failed to document staff work performance evaluations in personnel records # 4, and 5.
Employee # 4 was hired on January 23, 2013. A work performance evaluation was due by July 23, 2013, but was documented on July 26, 2013. In addition, the work performance evaluation lacked the signature and date of a supervisor/evaluator verifying that this was presented to the employee by the supervisor/evaluator.
Employee # 5 was hired on April 4, 2011. A work performance evaluation was documented on March 1, 2013; however the work performance evaluation lacked a supervisor/evaluator signature as of the date of this inspection.
The Project Director did not dispute the findings.
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Plan of Correction
The Director of Outpatient Services will review the review policy in the year 2014 and have a new employee review template for the year 2015. Currently both employees are required to fill out the document twice and sign twice which can allow for error.
The Director of Outpatient Services will meet with the employee during the time of the review and check for signatures on the employee portion prior to starting the review. The Director will then foward the reviews to the President of the Board to ensure all signatures are on the document.
The findings include:
Five personnel records were reviewed on January 22, 2014. Staff work performance evaluations were required in four personnel records. The facility failed to document staff work performance evaluations in personnel records # 4, and 5.
Employee # 4 was hired on January 23, 2013. A work performance evaluation was due by July 23, 2013, but was documented on July 26, 2013. In addition, the work performance evaluation lacked the signature and date of a supervisor/evaluator verifying that this was presented to the employee by the supervisor/evaluator.
Employee # 5 was hired on April 4, 2011. A work performance evaluation was documented on March 1, 2013; however the work performance evaluation lacked a supervisor/evaluator signature as of the date of this inspection.
The Project Director did not dispute the findings.
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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 a review of client records, the facility failed to document a complete client record on an individual, which includes information relative to the client's involvement with the project in six of twenty four client records.
The findings include:
Twenty four client records were reviewed on January 22, 2014. Follow up information was required in eight client records. The facility failed to provide a complete client record, including follow up information, for client #s 13, 14, 15, 18, 21, and 24.
Client #13 was admitted 7-23-13 and was discharged on 9-20-13. A follow up was to be completed no later than 9-27-13; however there was no follow up documented as of the date of this inspection.
Client #14 was admitted 3-5-13 and was discharged on 5-24-13. A follow up was to be completed no later than 5-31-13; however there was no follow up documented as of the date of this inspection.
Client #15 was admitted 9-10-13 and was discharged on 11-26-13. A follow up was to be completed no later than 12-3-13; however there was no follow up documented as of the date of this inspection.
Client #18 was admitted 8-28-13 and was discharged on 1-9-14. A follow up was to be completed no later than 1-16-14; however there was no follow up documented as of the date of this inspection.
Client #21 was admitted 7-23-12 and was discharged on 1-9-14. A follow up was to be completed no later than 1-16-14; however there was no follow up documented as of the date of this inspection. Additionally, a case consultation was due to be completed on 12-16-13; however there was no case consult documented in the client record as of the date of this inspection.
Client #24 was admitted 10-30-13 and was discharged on 12-6-13. A follow up was to be completed no later than 12-13-13; however there was no follow up documented as of the date of this inspection.
The Project Director did not dispute the findings.
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Plan of Correction
The Director and the Clinical Director will do a mini training on follow up procedures and have the employee's sign off on the training on 2/7/14.
The lead couneslor whom is in charge of documenting discharges, will create a spreadsheet of all 7 day follow up's needed and request a DAP note from all employees when the 7 day is completed. She will log the completion in her 7 day follow up.
The Clinical Director will check the spreadsheet weekly to ensure that all staff is completing the 7 day follow up, and review the deficiencies if necessary in the weekly staff meeting.
The Clinical Director will provide a report to the Project Director weekly during supervison of the progress of compliance with this policy. |