INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 20-22, 2023, 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:
|
Plan of Correction
|
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of administrative documents and an interview with facility staff, the project director failed to annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Genesis House, Inc. failed to annually update and sign a written manual delineating project policies and procedures.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and ensuring that policy and procedure are up to date and in line with DDAP requirements. As policies and procedures are reviewed, updated, and changed, the Executive Director/Regional Clinical Director, will be signing off that each one and proceed annually updating and signing the written manual delineating our policies and procedures.
|
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.
|
Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Client #1 was admitted on June 21, 2023, and was still active at the time of the inspection. The treatment plan was dated June 26, 2023.
Client #2 was admitted on March 23, 2023, and was still active at the time of the inspection. The treatment plan was dated April 20, 2023.
Client #3 was admitted on March 9, 2023, and was still active at the time of the inspection. The treatment plan was dated April 19, 2023.
Client #4 was admitted on December 21, 2022 and was still active at the time of the inspection. The treatment plan was dated December 27, 2022.
Client #5 was admitted on December 13, 2022, and was discharged on July 12, 2023. The treatment plan was dated February 6, 2023.
Client #6 was admitted on July 26, 2023 and was discharged on September 19, 2023. The treatment plan was dated August 8, 2023.
Client #7 was admitted on April 13, 2023 and was discharged on August 17, 2023. The treatment plan was dated July 24, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Genesis House, Inc. failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Throughout treatment at Genesis House Inc., support services are identified and documented in the client file (i.e. biopsychosocial, relapse prevention plan, and during the initial intake assessment). Genesis House Inc., will provide a retraining to all Genesis House Inc. employees by January 31, 2024, to ensure staff are documenting supports and supportive services directly in the Treatment Plan.
The Regional Clinical Director will collaborate with the Director of Training to provide training to all clinical staff members on documentation and treatment planning.
Each facility's clinical director to ensure this training takes place during individual supervision, group supervision, and/ or staff meetings.
Each clinical director will then be responsible to collaborate with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria.
When a deficiency is identified, the Clinical Director of the facility will work with the clinician to get the appropriate information corrected in the treatment plan for the following review.
The clinician will then be responsible for making the corrections and informing the clinical director for review and approval.
The clinical director will follow up with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria.
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #1 was admitted on June 21, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 26, 2023, and the next update was due no later than August 26, 2023; however, there was no treatment plan update documented in the record until August 28, 2023.
Client #3 was admitted on March 9, 2023, and was still active at the time of the inspection. A treatment plan update was completed on June 6, 2023, and the next update was due no later than August 6, 2023; however, there was no additional treatment plan update documented in the client record.
Client #4 was admitted on December 21, 2022, and was still active at the time of the inspection. A comprehensive treatment plan update was completed on December 27, 2022, and the next update was due no later than February 27, 2023; however, there was no treatment plan update documented in the record until April 18, 2023. Additionally, a treatment plan update was completed on May 23, 2023, and the next update was due no later than July 23, 2023; however, there was no treatment plan update documented in the client record until July 25, 2023.
This is a repeat citation from the October 20, 2021 and October 14, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 25, 2021 and October 2022 licensing inspection.
|
Plan of Correction
Genesis House, Inc. failed to document treatment plan updates within the regulatory timeframe.
Genesis House, Inc. will train/retrain all new and existing clinical employees on the importance of, and regulatory expectations of treatment plan updates on or before 60 days of the initial treatment plan.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and the review of client files.
The Compliance and Program Development Coordinator will be responsible for completing chart audits throughout the month each month and will monitor treatment plan update timelines using a clinical documentation audit tool. This tool will provide clinical staff the needed information to maintain documentation compliance.
They will then share their findings with the clinical director of each facility with expectations and a time line as to when corrections in the chart need to be completed.
The clinical director will follow up with the clinicians during supervision times and/or other times planned, to address the findings with the clinician, and develop a plan to make corrections as needed and/or make improvements moving forward.
The clinician will then be responsible for making the corrections and informing the clinical director for review and approval.
The clinical director will follow up with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria.
|
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy states that case consultations must be completed, at minimum, monthly.
Client #1 was admitted on June 21, 2023, and was still active at the time of the inspection There were no case consultations documented in this client record.
Client #2 was admitted on March 23, 2023, and was still active at the time of the inspection. There was only one case consultation, dated April 13, 2023, documented in this client record.
Client #3 was admitted on March 9, 2023, and was still active at the time of the inspection. There was only one case consultation, dated March 15, 2023, documented in this client record.
Client #4 was admitted on December 21, 2022, and was still active at the time of the inspection. There was only one case consultation, dated December 27, 2023, documented in this client record.
Client #5 was admitted on December 13, 2022, and was discharged on July 12, 2023. There were two case consultations, dated December 13, 2022 and July 12, 2023, documented in this client record.
Client #6 was admitted on July 26, 2023, and was discharged on September 19, 2023.There was one case consultation, dated July 26, 2023, documented in this client record.
Client #7 was admitted on April 13, 2023, and was discharged on August 17, 2023. There was one case consultation, dated April 13, 2023, documented in this client record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Genesis House, Inc. failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy states that case consultations must be completed, at minimum, monthly.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and ensuring that policy and procedure are up to date and in line with DDAP requirements. As policies and procedures are reviewed, updated, and changed, the Executive Director/Regional Clinical Director, will be signing off that each one and proceed annually updating and signing the written manual delineating our policies and procedures.
The current policy on Case Consultation is currently under review/revision at this time and is projected to be completed by December 31, 2023.
Genesis House will then ensure that the new policy and procedure is distributed to all staff for training and review to be completed by January 31, 2024.
Clinical Directors will then document when completing case consultation with clinicians and keep record for review.
|
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on October 20, 2021 and October 14, 2022, addressing the requirement that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Genesis House, Inc. failed to comply with plans of correction approved by the Department.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and the review of client files.
The Compliance and Program Development Coordinator will be responsible for completing chart audits throughout the month each month, to assure charts are up to regulatory standards.
|