INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26, 2021 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, Inc. 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for January 2020 through September 2021, the facility failed to provide documentation of an unannounced fire drill being conducted the months of August and September 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House has completed retraining of Fire Safety Drills with supervisors and all clinical staff. Genesis House's Lead Counselor and Clinical Director will share this responsibility of ensuring that the Fire Safety Drills are completed each week. Director will provide a reminder each first of the month to ensure that all Clinical Supervisors schedule random Fire Drills within their facilities. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the project fiscal management, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the fiscal year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to complete it's fiscal audit within the timeframe as prescribed by DDAP regulations.
Genesis House, Inc. will secure the services of a different independent fiscal auditor for 2021, thereby avoiding a future delays in completion of our annual fiscal audit moving forward. |
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 two of eight applicable personnel records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluation being reviewed and signed by the employee being evaluated.
Employee # 7 was hired as a counselor on July 20, 2020 and was still in this role at the time of the inspection. An annual written staff performance evaluation was provided however, the evaluation was not signed by the employee.
Employee # 9 was hired as a counselor on June 2, 2012 and promoted to clinical director on July 14, 2021 and was still in this role at the time of the inspection. An annual written staff performance evaluation was provided however, the evaluation was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc failed to provide an individual staff performance evaluation that was acknowledged and signed by the employee.
Genesis House, Inc. will designate our Administrative Assistant to monitor and track all staff performance evaluations moving forward to ensure compliance. |
709.28 (c) 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.
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Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 3, 5, and 6.
Client # 3 was admitted on August 26, 2021 and was still active at the time of the inspection. An authorization for funding occurred on August 26, 2021 without an informed and voluntary consent from the client for the disclosure of information.
Client # 5 was admitted on September 29, 2020 and was discharged on January 13, 2021. The client record indicated medical assistance number and billing amounts without a valid informed and voluntary consent from the client for the disclosure of information to a funding source.
Client # 6 was admitted on September 10, 2020 and was discharged on April 12, 2021. The client record indicated medical assistance number and billing amounts without a valid informed and voluntary consent from the client for the disclosure of information to a funding source.
Client # 7 was admitted on August 31, 2020 and was discharged on April 26, 2021. The client record indicated phone calls to an employer on March 3, 4, 5, 12, 15, and 17, 2021 without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House's Training Director will retrain all staff in regards to the appropriate completion of consent forms. This training will include the completion of how to review a consent form with a client, through the use of role play, visual assistance, and how to appropriately complete a consent form. Training Director and Clinical Directors will conduct frequent random samples of consent forms in order to monitor for compliance and will address accordingly. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had "SET" which stands for signed electronic telehealth.
Client # 1 was admitted on June 9, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 9, 2021 to a funding agency, department of corrections, and a probation officer did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 2 was admitted on March 17, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 30, 2021 to an attorney did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 6 was admitted on September 10, 2020 and was discharged on April 12, 2021. An informed and voluntary consent from the client for the disclosure of information dated September 10, 2020 to medical assistance, a probation officer, and MAT provider with a second consent form dated September 24, 2020 did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 7 was admitted on August 31, 2020 and was discharged on April 26, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 31, 2020 to a funding agency, and a probation officer did not have a valid signature by the client but instead had "SET" in the signature line.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House reviewed this direction from DDAP inspector immediately, as this was a misunderstanding that with tele services being permitted due to the pandemic that we were able to use SET. This understanding was identified via MCOs and OMHSAS. Genesis House polices have been adjusted to require that all initial appointments are completed in person, to avoid the use of SET on documentation in which verbal consent cannot be used, specifically consent forms. If someone is unable to make arrangements to attend an initial assessment in person, the location Clinical Director will be notified in order to determine an individualized plan to meet that individual's needs. |
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 three of seven client records reviewed, the facility failed to document an individual treatment and rehabilitation plan being developed with the client within the third treatment session in accordance with the facility policy and procedure manual.
Client # 3 was admitted on August 26, 2021 and was still active at the time of the inspection. The initial treatment plan occurred on August 26, 2021. The comprehensive treatment plan was due to be completed on September 24, 2021. There was not a comprehensive treatment plan documented in the client record.
Client # 4 was admitted on May 13, 2021 and was still active at the time of the inspection. The initial treatment plan occurred on May 13, 2021. The comprehensive treatment plan was due to be completed on July 21, 2021 but did not occur until August 5, 2021. Also, the comprehensive treatment plan did not include a client acknowledgement of being developed with the client.
Client # 7 was admitted on August 31, 2020 and was discharged on April 26, 2021. The initial treatment plan occurred on September 2, 2020. The comprehensive treatment plan was due to be completed on September 23, 2020 but did not occur until January 14, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House Clinical Supervisors will provide retraining in staff meeting regarding the timeline requirements related to treatment plan updates; including initial treatment plans, master treatment plans, and updates. As a team, we will have discussions regarding barriers to meet these requirements and problem solve together as to how to overcome these barriers. Individual clinicians who struggle especially with this area, will be provided additional direction and support in individual supervision. This will continue to be monitored through regular file reviews. |
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 five of six applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans shall being reviewed and updated at least every 60 days in client records # 1, 4, 5, 6, and 7.
Client # 1 was admitted on June 9, 2021 and was still active at the time of the inspection. A treatment plan occurred on June 29, 2021. A treatment plan update was due to occur on August 29, 2021 but did not occur until September 27, 2021.
Client # 4 was admitted on May 13, 2021 and was still active at the time of the inspection. A treatment plan occurred on August 5, 2021. A treatment plan update was due to occur on October 5, 2021. There was no other treatment plan update documented in the client record.
Client # 5 was admitted on September 29, 2020 and was discharged on January 13, 2021. A treatment plan occurred on November 2, 2020. A treatment plan update was due to occur on January 2, 2021. There was no other treatment plan update documented in the client record.
Client # 6 was admitted on September 10, 2020 and was discharged on April 12, 2021. A treatment plan occurred on January 24, 2021. A treatment plan update was due to occur on March 25, 2021 but did not occur until April 12, 2021.
Client # 7 was admitted on August 31, 2020 and was discharged on April 26, 2021. A treatment plan occurred on January 14, 2021. A treatment plan update was due to occur on March 14, 2021. There was no other treatment plan update documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 20, 2019 and December 18, 2017 annual licensing inspection.
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Plan of Correction
Genesis House Clinical Directors will review in staff meeting the policy related to treatment plans needing to be updated every 60 days. As a team, we will have discussions regarding barriers to meet these requirements and problem solve together as to how to overcome these barriers. Individual clinicians who struggle with this area, will be provided additional direction and support in individual supervision. This will continue to be monitored through regular file reviews. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide a complete client record to include an aftercare plan in accordance with the facility policy and procedure manual for an aftercare to be completed upon a client ' s successful discharge.
Client # 5 was admitted on September 29, 2020 and successfully discharged on January 13, 2021. There was not an aftercare plan documented in the client record.
Client # 7 was admitted on August 31, 2020 and successfully discharged on April 26, 2021. There was not an aftercare plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy review will occur with all clinical staff in staff meetings This will continue to be monitored through regular file reviews |
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 two of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicates a follow-up to the client to occur thirty days, sixty days and one year for successful discharge and one week for an against medical advice discharge.
Client # 5 was admitted on September 29, 2020 and discharged on January 13, 2021. There was no follow-up information documented in the client record.
Client # 7 was admitted on August 31, 2020 and discharged on April 26, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House's Director will update the Office Policy to be in alignment with Genesis House policy and procedure manual. Follow ups are required for unsuccessful discharges, within 7 days of that discharge; however, Genesis House's policy is not to do a follow up for successful discharges. The updates to this policy were not made agency wide, thus resulting in the confusion. Corrections will be made across all locations. |