INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Genesis House 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
During a licensing inspection on December 2, 2019, in one employee record the facility failed to provide documentation of a counselor assistant with a high school diploma receiving direct observation during the first three months of employment. Also, there was no documentation of at least one hour of direct observation during the close supervision period.
Employee # 5 was hired as a counselor assistant on March 12, 2018 and was still 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
The Director and RCD met on 11/19/2019 at 4 PM to review this citation that was received in the HBG office. On 11/19/2019, the Director had an emergency meeting with all the managers to review the citation received. 11/20/2019 the Director added a form to the new hire orientation plan for the clinical director to review, which includes providing proof of at least 2 hours per week of direct observation. On 12/2/2019 the RCD reviewed that this citation took place in the Bloomsburg office as well. This corrective action plan as of 12/2/2019: The RCD reviews all CA supervision notes weekly to ensure that this policy is being upheld. The Director will review the CA notes once a month to ensure compliance by the RCD and CD. |
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
During a licensing inspection and Staffing Requirements Facility Summary Report review conducted on December 2, 2019, the project failed to comply with the client/staff and client/counselor Full Time Equivalent (FTE) counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
Employee # 1 was hired as the project director/facility director on April 4, 2011. Employee # 1 reported to have 2 hours per week devoted to their 2 clients on their caseload. The FTE counselor ' s caseload calculation is as follows: 2/40 = .05(FTE); 2/.05= 40, which equals to a client/counselor ratio of 40:1.
Employee # 2 was hired as a clinical supervisor on April 11, 2014. Employee # 2 reported to have 3 hours per week devoted to their 3 clients on their caseload. The FTE counselor ' s caseload calculation is as follows: 3/40 = .075(FTE); 3/.075= 40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director and The RCD in this case did meet the 35/1 ratio, the RCD filled out these reports incorrectly writing 2/2 and 3/3 rather than the hours allotted for client hours. The Director reviewed with RCD how to complete her staffing requirements. The Director will oversee that these staffing requirements are completed correctly and assure that all staffing are meeting the 35/1 ratio by having the RCD monitor compliance weekly with the clinical directors to ensure they are meeting the 35/1 ratio.To ensure compliance the RCD will send a weekly report of the ratios to ensure compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
During a licensing inspection conducted on December 2, 2019, the facility failed to follow the project's policy and written procedures 709.24 for the completion of a comprehensive treatment plan within three individual sessions in two of seven records reviewed.
Client # 1 was admitted on October 15, 2019 and was still active at the time of the inspection. The initial treatment plan was developed on October 15, 2019. The comprehensive treatment plan was not developed within three individual sessions.
Client # 2 was admitted on May 2, 2019 and was still active at the time of the inspection. The initial treatment plan was developed on May 9, 2019. The comprehensive treatment plan was not developed within three individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The management team met to review the deficiencies on 12/3/2019. The CD reviewed the Master treatment plan requirements with all clinical staff in staff meeting held on 12/6/2019. The Training/HR director will provide a training on this process again with all staff on 1/10/2020. The Training/HR director will provide another training in Summer of 2020. Date to be determined in April of 2020. The CD is responsible for reviewing compliance of treatment planning. The CD will review all monthly admissions to ensure that the initial treatment plan and master treatment plan have been created within the required time frames. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
During a licensing inspection conducted on December 2, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 4.
Client # 4 was admitted November 14, 2018 and was still active at the time of the inspection. Consent to release forms in the client record showed an expiration date for November 13, 2019 with no updated forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The management team met to review the deficiencies on 12/3/2019. The CD reviewed release of information requirements with all clinical staff in staff meeting held on 12/6/2019. The CD is responsible for providing a list of clients whom have been in treatment for a period of 10 months to the primary counselor so that he/she/they are advised of what clients need releases of information updated. The CD will ensure that releases of information are updated by taking this list and checking the charts for compliance monthly.The clinical director will start this process as of 12/3/2019. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
During a licensing inspection conducted on December 2, 2019, the facility failed to provide a termination letter notifying one client in writing, of a decision to involuntarily terminate the client's treatment at the project.
Client # 5 was admitted on February 11, 2019 and administratively discharged on August 30, 2019. There was no documentation in the client record of a termination letter
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The management team met to review the deficiencies on 12/3/2019. The CD reviewed the discharge process with all clinical staff in staff meeting held on 12/6/2019. The Training/HR director will provide a training on this process again with all staff on 1/10/2020. The Training/HR director will provide another training in Summer of 2020. Date to be determined in April of 2020. The CD is responsible for reviewing compliance with all clients who have not been seen in over 15 days and upon signing the discharge summary ensure a 30 day letter has been sent. The RCD will review 5 charts per week per facility, where clients have not been seen in 15 days to ensure compliance. The RCD will review 5 charts per week per facility where clients are discharged to ensure compliance |