INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2008 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 December 24, 2008.
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Plan of Correction
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on an inspection of the physical plant the facility failed to provide a cover for the trash container located outside the facility.
The findings include:
A physical plant inspection was conducted on December 3, 2008. A "dumpster" trash container located outside the facility did not have a cover.
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Plan of Correction
Project director cancelled the dumpster on 12/10/08 and purchased a covered trash can to replace it. Facility director will monitor utilization of the trash can on weekly basis to ensure compliance with this standard. |
709.23(b)(2) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(2) Written reports of project operations.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document current board meeting minutes.
The finding include:
A review of the facility's policy and procedure manual and an interview conducted on December 3, 2008 with the Project Director confirmed that the facility could not produce current board of director meeting minutes for the last 12 months.
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Plan of Correction
Project director reviewed the standard with the governing body on 12/8/08 during the weekly directors meeting to ensure their understanding. Governing body agree to provide the project director with appropriate board meeting minutes for all subsequent board meetings on 12/8/08. Project director will place the meeting minutes in the facility's policy and procedures manual for the department's review upon receipt. Project director will monitor to ensure compliance by 12/31/08. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedure on client confidentiality and a review of the facility's HIPAA Right to Privacy Notice, the facility failed to include correct reference to 4 Pa. Code Subsection 255.5. The information provided in the HIPAA Right to Privacy Notice misinformed clients receiving drug and alcohol treatment services of their rights and protections regarding the confidentiality of any information which would identify them as a participant in drug and alcohol treatment services.
The findings include:
A thorough review of the facility's confidentiality policy and procedure regarding client records on December 2-3, 2008, revealed that the policy and procedure did not include reference to 4 Pa. Code Subsections 255.5 (a)(1) through 255.5 (c) as required.
The facility's HIPAA Right to Privacy Notice failed to inform clients that releases without client consent permitted under the HIPAA regulations may still be prohibited by state law and regulation and by federal regulation at 42 CFR Part 2. The HIPAA Right to Privacy Notice did not include any disclaimer for drug and alcohol treatment records.
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Plan of Correction
Project director will revise the facility's current confidentiality policy by 12/15/08 to address the correct reference to PA Code Subsection 255.5. Project director will secure govening body approval for the revised policy and add to the facility's policy and procedures manual by 1/5/09. Facility director will review the revised policy with facility staff on 1/8/09 to ensure their understanding. Project director met with the governing body on 12/8/08 to address the issue of the Hipaa privacy notice. Project director will create a confidentiality form on 12/15/08 and submit for governing body approval by 1/5/09. The new confidentiality form will address the disclaimer relating to state and federal confidentiality laws and the Hippa form. Facility director will review the new confidentiality form with facility staff on 1/8/09 to ensure their understanding. New form will be provided to the facility's clients in conjunction with the Hipaa notice and each will be placed in the client file. Facility director will monitor weekly during the client chart reviews by 1/31/09 to ensure appropriate compliance. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records, the facility failed to provide complete documentation on client medication in one of one client records.
The findings included:
On December 3, 2008, eleven client records were reviewed. One client record was required to include medication documentation. The facility failed to include the frequency at which the medication was to be taken in client record # 6.
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Plan of Correction
Facility director will retrain all facility staff on the appropriate completion of the facility's health questionnaire and biopsychosocial assessment, focusing on the appropriate documentation of client medication regimes, at the weekly staff meeting on 12/11/08. Facility director will monitor weekly during weekly client chart reviews by 12/31/08 to ensure appropriate compliance. |
709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
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Observations
Based on an interview with the Facility Director and the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient treatment activity.
The findings included:
During the licensing inspection conducted on 12/3/2008, client census material provided by the Facility Director and an interview with the Facility Director confirmed that the current census for active clients was at 102. The maximum approved capacity on the day of the inspection was 90.
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Plan of Correction
Project director submitted a letter to the department requesting an increase in the facility's maximum approved client capacity on 12/1/08. Project director will review current active client totals with the facility director on a weekly basis to monitor for appropriate compliance with this standard. Project director will ensure that the facility maintains a census within the parameters of the facility's approved maximum capacity. |