INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27, 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 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure exits from rooms and from the nonresidential facility are unobstructed. The main entrance/exit to the facility was kept locked from the inside and was unable to be opened without a key creating a fire safety issue.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to ensure exits are unobstructed.
Genesis House will keep all exits unlocked or a new door will be installed that is equipped with a push bar to ensure all individuals will be able to safely exit the building.
Director is in discussion currently with the land lord of our Bloomsburg location to install a new door equipped with a push bar. |
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 one of three 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 # 2 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) (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 six 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 February 18, 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 February 18, 2021 to a funding agency, a probation officer, treatment court, and case manager and additional consent to release forms dated June 9, 2021 to children and youth services and a probation officer did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 3 was admitted on February 25, 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 February 25, 2021 to a funding source, a probation officer, community corrections, and department of corrections funding did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 4 was admitted on July 8, 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 July 8, 2021 to a funding source, attorney, and CMSU and additional consent to release forms dated September 9, 2021 to family court did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 5 was admitted on May 8, 2020 and was discharged on April 22, 2021. An informed and voluntary consent from the client for the disclosure of information dated May 8, 2020 to a funding source, case manager, and emergency contact and additional consent to release forms dated May 22, 2020 to a probation officer did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 6 was admitted on August 18, 2020 and was discharged on August 26, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 18, 2020 to a funding source, case manager, supervision officer, and emergency contact and additional consent to release forms dated October 2, 2020 to a psychiatrist and an additional consent to release form dated March 17, 2021 to a probation officer did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 7 was admitted on August 13, 2020 and was discharged on April 15, 2021. An informed and voluntary consent from the client for the disclosure of information dated August 13, 2020 to a funding source, probation officer, case manager, SCA, and emergency contact 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. |
709.93(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 two 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 indicate a follow-up to the client 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 May 8, 2020 and discharged on April 22, 2021. There was no follow-up information documented in the client record.
Client # 7 was admitted on August 13, 2020 and discharged on April 15, 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 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 location. |