INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 28 - 29, 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 Ministries 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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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 a review of client records, the facility failed to document a written, informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven records reviewed on October 28 - 29, 2021.Client # 1 was admitted August 27, 2021. The client's name and diagnosis were released to the insurance company for billing purposes without the written consent of client # 1. Client # 2 was admitted September 5, 2021. A progress report was released to the probation officer by fax on October 26, 2021 without the client's written consent.Client # 3 was admitted October 3, 2021. The client's name and diagnosis were released to the insurance company for billing purposes without the written consent of client # 3. In addition, a progress report was released to the probation officer by fax on October 13, 2021 without the client's written consent.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 8 - 9, 2020 licensing inspection.
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Plan of Correction
The Director held a meeting on November 3, 2021, the clinical staff was aware and had the forms needed but not have the client sign them. Going forward intake and counselors will make sure there is a consent form signed by the client for any files going out to any third-party. A copy will be given to the clients and will also be included in client records. The Director will monitor the client files monthly. The corrections will be made by November 24, 2021. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the name of the person, agency or organization to whom disclosure is made in two of seven records reviewed on October 28 - 29, 2021.The consent to release information forms documented during the intake process did not include the name of the person, agency or organization to whom disclosure is made in the following client records:Client # 1 was admitted August 27, 2021. Client # 3 was admitted October 3, 2021. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director held a meeting on November 3, 2021, the Director made it aware that during the intake process a consent to release information must be included the name of a person agency or organization. This must be signed and given a copy to the client it will also be in the clients records. This will take affect starting the next client intake admission process. This will be monitored by the Director monthly. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the specific information disclosed in two of seven records reviewed on October 28 - 29, 2021.The consent to release information forms documented during the intake process did not include the specific information disclosed in the following client records:Client # 1 was admitted August 27, 2021. Client # 3 was admitted October 3, 2021. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
November 3, 2021 in a meeting the Director stated that the clinical staff such as intake director, counselor and case manager will have a release of information form signed and dated and will be contained in client record. Staff will ensure that this form will be filled out for any and all information disclosed to any third party. Also, this form will indicate the specific information to be disclosed and the purpose of the disclosure and a copy of the consent will be offered to the client. These releases will be kept in the client file. The Director will monitor that the correction has been made. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the purpose of disclosure in two of seven records reviewed on October 28 - 29, 2021.The consent to release information forms documented during the intake process did not include the purpose of disclosure in the following client records:Client # 1 was admitted August 27, 2021. Client # 3 was admitted October 3, 2021. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director held a meeting on November 3, 2021, going forward clients are to sign a consent that includes the purpose of disclosure contained in the client record. This is to be kept in the clients files. The Director will monitor this in the client files monthly. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination within seven days of admission, per facility policy, in five of seven client records reviewed August 28 - 29, 2021.The following client records did not include documentation of the client's physical examination:Client # 1 was admitted August 27, 2021.Client # 2 was admitted September 5, 2021.Client # 3 was admitted October 3, 2021.Client # 5 was admitted May 10, 2021 and discharged October 10, 2021.Client # 6 was admitted September 17, 2021 and discharged October 1, 2021.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 8 - 9, 2020 licensing inspection.
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Plan of Correction
The Director held a meeting on November 3, 2021.The clients will be asked at intake/admission if they have had a physical within 6 months, if they cannot get it from the Dr that gave them a physical or they have not had one done, then intake must schedule a physical with our contracting physician's office. Clients must have a physical within 7 days of their admission. This correction will be monitored by the director. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan during the intake process, per facility policy, in four of seven client records reviewed August 28 - 29, 2021.No preliminary treatment plans were documented in the following records:Client # 4 was admitted May 16, 2021 and discharged June 16, 2021.Client # 5 was admitted May 10, 2021 and discharged October 10, 2021.Client # 6 was admitted September 17, 2021 and discharged October 1, 2021.Client # 7 was admitted March 4, 2021 and discharged October 13, 2021.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 8 - 9, 2020 licensing inspection.
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Plan of Correction
The Director held a meeting on November 3, 2021. The counselor will document the preliminary and the rehabilitation plan the first day of treatment following the intake process. Client will sign it and it'll be kept in the clients' files. The Director will monitor this correction. And the correction will be made going forward. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 a review of client records, the facility failed to document an individual treatment and rehabilitation plan within thirty days of admission, per facility policy, in two of five client records reviewed August 28 - 29, 2021.Client # 5 was admitted May 10, 2021 and discharged October 10, 2021. No individual treatment plan was documented for client # 5. Client # 7 was admitted March 4, 2021 and discharged October 13, 2021. The individual treatment plan was not documented until September 21, 2021.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 8 - 9, 2020 licensing inspection.
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Plan of Correction
November 3, 2021 the Director made it aware to the counselors that the individual treatment and rehabilitation plan must be in the client's files within 30 days. Going forward all individual treatment and rehabilitation plans will be in client records within 30 days. The Director monitor this he will be checking client files after 30 days. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a review and update of treatment and rehabilitation plans at least every 30 days in one of two records reviewed on October 28 - 29, 2021.Client # 1 was admitted August 27, 2021. The individual treatment plan was documented September 16, 2021. No treatment plan updates were documented in record # 1.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director held a meeting on November 3, 2021. Going forward the treatment and rehabilitation plans will be updated every 30 days and will be put into the client's records. The Director will monitor this and will be checking client records every 30 days. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete client record including a record of services provided in four of seven records reviewed on October 28 - 29, 2021.The following records did not include documentation of a record of services provided.Client # 1 was admitted August 27, 2021.Client # 2 was admitted September 5, 2021.Client # 3 was admitted October 3, 2021.Client # 6 was admitted September 17, 2021 and discharged October 1, 2021.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 8 - 9, 2020 licensing inspection.
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Plan of Correction
November 3, 2021 the Director held a meeting with the clinical staff. Going forward the counselors will fill out record of services for individual and group sessions. And this will be kept in the clients files. The Director will monitor all corrections. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a complete client record including verification that work done by the client at the project was an integral part of their treatment and rehabilitation plan in three of four records reviewed on October 28 - 29, 2021.Client # 1 was admitted August 27, 2021.Client # 2 was admitted September 5, 2021.Client # 3 was admitted October 3, 2021.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 8 - 9, 2020 licensing inspection.
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Plan of Correction
November 3, 2021 the Director held a meeting and the issue was discussed with clinical staff and going forward the clinical staff will include verification of work done by the clients it will also include the work done by the clients is an Intercal part of their treatment and rehabilitation plan. The Director will monitor that the corrections are made. |