INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 2024, 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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704.9(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
Based on a review of eleven personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #8 was hired on July 30, 2024 as a counselor assistant and is still current in that position. Employee #8 has a bachelor's degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Employee #8 had supervision notes from August 29, 2024 - October 4, 2024, that only documented formal case reviews, there was no documentation of direct observation. In addition, the supervision notes provided were not signed by a trained counselor or clinical supervisor. The signature line was blank on each note.
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. 704.9(c) Supervised Period ? Counselor Assistant Supervision
- Deficiency: A counselor assistant with a bachelor's degree (Employee #8) was not consistently supervised as required, lacking documented direct observation and a signed supervision record.
- Corrective Action Plan:
o Immediate Action: Assign a trained counselor or clinical supervisor to directly observe Employee #8 for one hour each week, as required by regulation, starting immediately.
o Documentation: Update supervision records to include direct observation notes and ensure that each session is signed by the supervisor. Implement weekly audits by the program director to confirm supervision documentation is complete.
o Staff Training: Conduct a refresher training for all clinical supervisors on supervision requirements and documentation standards.
o Completion Date: Immediate for weekly observation; full compliance to be reviewed and documented within 30 days.
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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 follow their policy to complete psychosocial evaluations at intake in five out of six applicable records reviewed.
The facility completes the psychosocial evaluations during the first session, per policy.
Client #1 was admitted on November 29, 2023 and was still current at the time of the inspection. Client #1 did not have the psychosocial evaluation completed during the first session.
Client #2 was admitted on April 30, 2024 and was still current at the time of the inspection. Client #2 did not have the psychosocial evaluation completed during the first session.
Client #3 was admitted on May 22, 2024 and was still current at the time of the inspection. Client #3 did not have the psychosocial evaluation completed during the first session.
Client #4 was admitted on May 5, 2023 and was discharged on March 5, 2024.Client #4 did not have the psychosocial evaluation completed during the first session.
Client #6 was admitted on May 9, 2024 and discharged on July 24, 2024.Client #6 did not have the psychosocial evaluation completed during the first session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.91(b)(6) Intake and Admission ? Psychosocial Evaluation
- Deficiency: Psychosocial evaluations were not completed during the first session for five out of six applicable client records.
- Corrective Action Plan:
o Policy Enforcement: Reinforce existing policy with all intake staff, ensuring psychosocial evaluations are completed within 7 days of the initial intake assessment date.
o Quality Checks: Implement a weekly review process to verify that psychosocial evaluations are completed on time for all new admissions.
o Training: Provide refresher training to intake counselors on the importance of timely evaluations as part of comprehensive client care.
o Completion Date: Immediate; policy adherence will be reviewed for compliance by the end of each week.
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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 service on individual treatment plans in two out of six applicable records reviewed.
Client #3 was admitted on May 22, 2024, and was still active at the time of the inspection. There were no support services documented on the client's May 28, 2024, comprehensive treatment plan.
Client #6 was admitted on May 9, 2024, and was discharged on July 24, 2024. There were no support services documented on the client's June 3, 2024, comprehensive treatment plan.
This is a repeat citation from the October 4, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92(a)(3) Treatment and Rehabilitation Services ? Support Services Documentation
- Deficiency: Individual treatment plans for Clients #3 and #6 lacked documentation of proposed support services.
- Corrective Action Plan:
o Standard Update: Amend treatment planning forms to include a mandatory section for support services, ensuring that all treatment plans outline relevant external resources.
o Counselor Training: Conduct training for counselors to reinforce the inclusion of support services in treatment planning and documentation.
o Monitoring: The clinical supervisor will conduct monthly audits to confirm the inclusion of support services in all treatment plans.
o Completion Date: Forms to be updated immediately; training to be completed within 2 weeks.
Client #3's counselor has spoken with them about support services and are working together to identify support services and add them to the treatment plan.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four out of seven records reviewed,
Client #2 was admitted on April 30, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plans dated April 30, 2024 and August 5, 2024 indicated weekly individual counseling sessions and group sessions two times a week. For the week of May 5-11, 2024, the client had no documented group sessions. For the week of August 25-31, 2024, the client only had one group session and no documented individual session. For the week of September 8-14, 2024, the client had no documented group sessions.
Client #4 was admitted on May 5, 2023 and discharged on March 5, 2024. The individual treatment and rehabilitation plans dated November 12, 2023 and February 12, 2024 indicated individual sessions weekly, and group sessions two times a week. There was no documentation of an individual or group sessions the week of January 21-27, 2024.
Client #6 was admitted on May 9, 2024 and discharged on July 24, 2024. The individual treatment and rehabilitation plan dated June 3, 2024 indicated weekly individual sessions. There was no documentation of weekly sessions from June 16 - 22, 2024, June 23 - 29, 2024, and June 30 - July 6, 2024.
Client #7 was admitted on March 22, 2023 and discharged on October 4, 2024. An individual treatment and rehabilitation plan update dated November 7, 2023 indicated one individual session weekly and two group sessions weekly. The weeks of November 19 - 25, 2023 and December 31, 2023 - January 6, 2024, there was no documentation of an individual counseling sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(c) Treatment and Rehabilitation Services ? Counseling Services According to Treatment Plan
- Deficiency: Four client records indicated discrepancies between scheduled and documented counseling services.
- Corrective Action Plan:
o Scheduling System: Update our scheduling and documentation procedures to ensure alignment with each client's treatment plan.
o Counselor Accountability: Require all counselors to verify completed sessions in the system weekly and cross-reference against each client's plan.
o Audit: Conduct bi-weekly audits of client records to ensure adherence to scheduled services and address any discrepancies immediately.
o Completion Date: New scheduling and verification protocols to be implemented immediately; first audit to occur within two weeks.
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