INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis House-Harrisburg 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 and a plan of correction is due on February 20, 2010.
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Plan of Correction
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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
Based on a review of the staffing requirements facility summary report form completed by the facility on January 28, 2010 and a discussion with the Project Director and Facility Director on January 28, 2010, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Three counselors caseloads were reviewed on January 28, 2010. Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, one counselor exceeded the caseload of 35:1. The counselors represented by personnel records # 2 and had caseloads under 35:1. The counselor represented by personnel record #4 had a caseload of 39:1, which exceeded the maximum of 35:1.
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Plan of Correction
Project director met with the facility director on 2/9/10 to develop and implement an action plan to bring the facility staff to client ratios into compliance. The plan consisted of more fully utilizing the newly hired counseling staff and transferring several clients from the staff whose caseload was out of compliance to other available clinical staff whose client caseloads could accommodate the additonal clients. Facility director will monitor staff to client ratios on a weekly basis coordinating new client referals to ensure consistent compliance among all clinical staff of the facility by 2/26/10. |
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 administrative policy and procedures manual and an interview with the Project Director and Facility Director, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in four of six client records. One of six client records failed to provide documentation of a psychosocial evaluation.
The findings include:
Six client records were reviewed on January 28, 2010. Six client records required the completion of psychosocial evaluations. The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 1, 2, 3, and 4. Client record #6 did not contain a psychosocial evaluation.
Client # 1 was admitted on June 2, 2009. The psychosocial evaluation was completed on June 2, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 2 was admitted on August 18, 2009. The psychosocial evaluation was completed on September 1, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 3 was admitted on December 3, 2009. The psychosocial evaluation was completed on December 7, 2009. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client record #4 was admitted on March 20, 2009. The psychosocial evaluation was completed on December 7, 2009. The psychosocial evaluation did not include a clinical assessment of the client and only included historical information.
Client #6 was admitted on October 24, 2009. The psychosocial evaluation was not completed.
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Plan of Correction
Project director will retain the facility staff on the appropriate completion of the facility's psychosocial evaluation process on 2/9/10, providing special emphasis on the clinical assessment component of the evaluation process.
Facility director will monitor weekly during the clinical chart review process to ensure consistent compliance by 2/26/10. |
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 a review of six client records and an interview with the Project Director and Facility Director the facility failed to document treatment plan reviews and updates within sixty days, in four of six client records.
The findings include:
Six client records were reviewed on January 28, 2010. Five client records required treatment plan review and updates. In accordance with the facility policy, treatment plan review and updates are required to be completed every sixty days. The facility failed to document treatment plan reviews and updates within sixty days, in client records # 1, 4, 5, and 6.
In client record # 1, the client was admitted on June 2, 2009. The comprehensive treatment plan was completed on June 10, 2009. The first treatment plan update was due no later than August 10, 2009; was not completed until November, 2009. The facility failed to document the completion of the treatment plan update within sixty days.
In client record # 4, the client was admitted on March 20, 2009. The comprehensive treatment plan was completed on March 26, 2009. The first treatment plan update was due no later than May 26, 2009. There were no treatment plan updates documented in client record # 4.
In client record # 5, the client was admitted on March 6, 2009. The comprehensive treatment plan was completed on April 28, 2009. The first treatment plan update was due no later than June 28, 2009 and was not completed until July 10, 2009. The facility failed to document the completion of the first treatment plan update within sixty days.
In client record #6, the client was admitted on October 24, 2009. The comprehensive treatment plan was completed on November 18, 2009. The first treatment plan update was due no later than January 18, 2009. The facility failed to document the first treatment plan update within sixty days.
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Plan of Correction
Project director will retrain the facility staff on the appropriate completion of the facility's treatment plan update procedures on 2/9/10 to ensure their understanding.
Facility director will monitor weekly during the clinical chart review process to ensure consistent compliance with facility policy by 2/26/10. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of six client records, a review of facility policy and procedure and an interview with the Project Director and Facility Director on January 28, 2010, the facility failed to document a case consultation in two of five client records.
The findings include:
Six client records were reviewed on January 28, 2010. Case consultations were required in four client records. The facility did not document a case consultation in client records #1 and 4. The facility policy required a case consultation to be completed every 90 days.
In client record #1 the client was admitted on June 2, 2009. In accordance with facility policy the initial case consultation was due on June 2, 2009. The next case consultation was due to be completed no later then September 2, 2009. The was no documentation of the second case consultation in the client record.
In client record #4, the client was a admitted on March 20, 2009. The second case consultation was due to be completed no later then June 20, 2009. The second case consultation was not completed until August 12, 2009. The second case consultation was not completed with the 90 day timeframe.
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Plan of Correction
Project director will retrain the facility staff on the appropriate completion of the facility's case consultation procedures on 2/9/10 to ensure their understanding.
Facility director will monitor weekly during the clinical chart review process to ensure consistent compliance with facility policy by 2/26/10. |
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 six client records and an interview with the Project Director and the Facility Director on January 28, 2010, the facility failed to document follow-up attempts in one of two client records in accordance with agency policy.
The findings include:
Six client records were reviewed on January 28, 2010. Two of six records were required to document follow-up attempts. Follow up was not documented in one of two client records.
In client record # 4, the client was admitted on March 20, 2009 and discharged on August 12, 2009. There was no follow attempt documented in the client record.
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Plan of Correction
Project director will retrain the facility staff on the appropriate completion of the facility's follow up contact procedures on 2/9/10 to ensure their understanding.
Facility director will monitor the completion of the facility's follow up procedures on a monthly basis by 2/26/10 to ensure consistent compliance. |