INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18-19, 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 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on applicable personnel records reviewed, the facility failed to provide documentation of clinical supervision training for a clinical supervisor who does not meet the required experience supervising others in one of one record.
Staff #2 was hired as counselor on February 23, 2020 and promoted to a clinical supervisor on September 19, 2021. Staff #2 does not have two years ' experience supervising others and did not complete the clinical supervision training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of December 1, 2023 the Clinical Supervisor position will be changed to Counselor therefore ensuring the deficiency does not recur. The Director will ensure the staff #2 signs proper documentation noting the change from clinical supervisor to Counselor. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on applicable personnel records reviewed, the facility failed to provide documentation of monthly meetings for the clinical supervisor and their supervisor to discuss duties and performance for the first six months upon employment in one of one record.
Staff #2 was hired as counselor on February 23, 2020 and promoted to a clinical supervisor on September 19, 2021. Staff #2 did not have documentation of six months supervision upon promotion to clinical supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the licensing process it was discussed that the Clinical Supervisor position was not required. As of December 7, 2023 the Clinical Supervisor position will be changed to Counselor therefore ensuring the deficiency does not recur. The Director will ensure the staff #2 signs proper documentation noting the change from clinical supervisor to Counselor. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on applicable personnel records reviewed, the facility failed to provide documentation of six months supervision in one of one record. Per regulation, a counselor assistant with an approved bachelor ' s degree may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment.
Staff #3 was hired as a human resources specialist on January 19, 2020 and promoted to a counselor assistant on September 26, 2022. Based on a review of Staff #3 ' s personnel record, there was no documentation of supervision being completed from September 26, 2022 through March 26, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #3 will provide documentations for 6 months of supervision for counseling assistant beginning November 19th and continuing through the 6 month period.
The Supervising Counselor will meet with Assistant counselor to monitor monthly progress notes. |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy and procedure for staff development, the facility failed to adhere to their training year.
The facility ' s policy and procedure manual states their training year is completed from January-December. During review of staff development, the facility is conducting their training year from July-June.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of December 15 the Financial Director along with the administration staff will ensure the policies and procedures manual is changed to reflect the staff training year is conducted from July-June. All trainings will be monitored by the Financial director and admin Staff for accuracy to ensure deficiency does not recur.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of applicable personnel records, the facility failed to provide a mechanism to provide feedback on a completed training in accordance with the facility policy and procedure manual in six of six personnel records.
The facility policy and procedure manual indicated that staff are to complete a training feedback form and provide it to the facilitator who conducted the training. No training feedback documentation was provided for Staff #1, #2, #3, #4, #5, and #8.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As per Policy 704.11 (a) (3) Feedback Forms will be completed by employees at the end of the fiscal year. The policies will be updated to reflect the change. Financial Director and Assistant Counselor will audit employee files at the end of the fiscal year to ensure all forms have been added to their files. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide written individual training plans for two of eight records, Staff #1 and #8, and failed to develop the training plan with input from both the employee and the supervisor in six of eight records, Staff #2, 3, 4, 5, 6, and 7.
Staff #1 was hired as the project and facility director on January 19, 2020 and was still in this position at the time of the inspection. The facility failed to provide documentation of an individual training plan for this staff.
Staff #2 was hired as counselor on February 23, 2020 and promoted to a clinical supervisor on September 19, 2021. The training plan for Staff #2 did not show any documentation that it was developed with staff input.
Staff #3 was hired as a human resources specialist on January 19, 2020 and promoted to a counselor assistant on September 26, 2022. The training plan for Staff #3 did not show any documentation that it was developed with staff input.
Staff #4 was hired as the fiscal director on January 19, 2020 and was still in this position at the time of the inspection. The training plan for Staff #4 did not show any documentation that it was developed with staff input.
Staff #5 was hired as a technician on January 19, 2020 and was still in this position at the time of the inspection. The training plan for Staff #5 did not show any documentation that it was developed with staff input.
Staff #6 was hired as a technician on March 12, 2023 and was still in this position at the time of the inspection. The training plan for Staff #6 did not show any documentation that it was developed with staff input.
Staff #7 was hired as a technician on April 17, 2023 and was still in this position at the time of the inspection. The training plan for Staff #7 did not show any documentation that it was developed with staff input.
Staff #8 was hired as CFO/Support Staff on January 19, 2020 and was still in this position at the time of the inspection. The facility failed to provide documentation of an individual training plan for this staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will develop a train plan for Staff #1 and # 8 as of December 15, 2023
The facility will develop the training plan with input from both the employee and supervisor for staff #2,3,4,5,6 and 7 based on their hire date.
Moving forward the Director and the CFO will ensure all staff has a training plan implemented and the proper documentation is completed so this deficiency does not recur. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of applicable personnel records, the facility failed to document staff had completed HIV/AIDS and TB/STD training within the required timeframe in two of four personnel records.
Staff #2 was hired as counselor on February 23, 2020 and promoted to a clinical supervisor on September 19, 2021. The documentation in the staff record indicated five hours and forty-five minutes of HIV/AIDS training. This does not meet the Department ' s minimum of six hours.
The documentation in the staff record indicated three hours and fifteen minutes of TB/STD training. This does not meet the Department ' s minimum of four hours.
Staff #5 was hired as a technician on January 19, 2020 and was still in this position at the time of the inspection. The HIV/AIDS training as to be completed by January 19, 2022, but was not completed until October 3, 2023.
The TB/STD training was to be completed by January 19, 2022. There was no documentation that this training was completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from May 17, 2023 and October 5, 2022 licensing inspections.
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Plan of Correction
Staff #2 will complete HIV Aids Training - and TB, STD to meet the departments minimum hour requirements.
The TB, STD, HEP 4 hour training is scheduled for January 11, 2024.
The Financial Director and Assistant Counselor will monitor the employee files and DDAP training site to ensure all staff trainings are scheduled and completed.
Staff #5 is no longer an employee with the facility. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility staff schedule, the facility failed to provide at least one person with CPR certification and first aid training onsite during the twenty-four-hour schedule. The facility did not provide four weeks of staff schedules, but verified that the schedules are standardized with staff working the same shift on specified dates.
Staff #2 was hired as counselor on February 23, 2020 and promoted to a clinical supervisor on September 19, 2021. This staff member has does not have documentation of a current CPR certification.
Staff #6 was hired as a technician on March 12, 2023 and was still in this position at the time of the inspection. This staff member did not have documentation of CPR certification until October 3, 2023.
Staff #7 was hired as a technician on April 17, 2023 and was still in this position at the time of the inspection. This staff member did not have documentation of CPR certification until October 3, 2023.
On Sundays, the facility failed to provide at least one person with CPR certification from 12:00am to 8:00pm. Staff #2 worked from 1:00pm to 8:00pm. Staff #6 worked from 8:00am to 8:00pm. These staff members are the only staff available during their shifts. After Staff #6 ' s CPR certification was acquired on October 3, 2023, coverage was compliant.
On Mondays, the facility failed to provide at least one person with CPR certification from 6:00pm to 11:59pm. Staff #7 worked from 4:00pm to 8:00pm. Staff #6 worked from 8:00pm to 8:00am the next morning. These staff members are the only staff available during their shifts. After Staff #6 and #7 ' s CPR certifications were acquired on October 3, 2023, coverage was compliant.
On Tuesdays, the facility failed to provide at least one person with CPR certification from 12:00am to 8:00am and from 6:00pm to 11:59am. Staff #6 worked from 8:00pm the previous evening to 8:00am on Tuesday. Staff #7 worked from 12:00pm to 8:00pm. These staff members are the only staff available from 12:00am to 8:00am and from 6:00pm to 11:59pm. After Staff #6 and #7 ' s CPR certifications were acquired on October 3, 2023, coverage was compliant.
On Wednesdays, the facility failed to provide at least one person with CPR certification from 12:00am to 8:00am from 6:00pm to 11:59am. Staff #6 worked from 8:00pm the previous evening to 8:00am on Wednesday. Staff #7 worked from 4:00pm to 8:00pm. These staff members are the only staff available from 12:00am to 8:00am and from 6:00pm to 11:59pm. After Staff #6 and #7 ' s CPR certifications were acquired on October 3, 2023, coverage was compliant.
On Thursdays, the facility failed to provide at least one person with CPR certification from 12:00am to 8:00am from 6:00pm to 8:00pm. Staff #6 worked from 8:00pm the previous evening to 8:00am on Thursday. Staff #7 worked from 12:00pm to 8:00pm. These staff members are the only staff available from 12:00am to 8:00am and from 6:00pm to 8:00pm. After Staff #6 and #7 ' s CPR certifications were acquired on October 3, 2023, coverage was compliant.
On Fridays, the facility failed to provide at least one person with CPR certification 6:00pm to 8:00pm. Staff #7 worked from 4:00pm to 8:00pm. This staff member is the only staff available from 6:00pm to 8:00pm. After Staff #7 ' s CPR certifications was acquired on October 3, 2023, coverage was compliant.
On Saturdays, the facility failed to provide at least one person with CPR certification from 8:00am to 8:00pm. Staff #2 worked from 9:00am to 12:00pm. Staff #7 worked from 8:00am to 8:00pm. These staff members are the only staff available from 8:00am to 8:00pm. After Staff #7 ' s CPR certifications were acquired on October 3, 2023, coverage was compliant.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members will have an updated CPR certification by Tuesday December 6, 2023 Upon hiring new staff financial director and assistant counselor will schedule a CPR training to ensure they get certified. No staff will work a shift on their own that does not have CPR training.
Financial Director and Assistant Counselor will work together to ensure all certifications are current, |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of staff records, the facility failed to provide documentation of at least forty clock hours of annual training required for a counselor assistant for their first year in this position in one of one applicable record.
Staff #3 was hired as a human resources specialist on January 19, 2020 and promoted to a counselor assistant on September 26, 2022. Staff #3 was required to complete forty hours of training from September 2022 to September 2023. During the review of the staff record, ten training hours were able to be verified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #3 has completed 26 of the required training hours. The remaining 4 hours will be completed by February 1, 2024. The Supervising Counselor will monitor the Assistant Counselors progress by checking her training log monthly to ensure all trainings are completed according to the departments guidelines. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of The Staffing Requirements Facility Summary Report, the facility failed to have one FTE counselor for every eight adult clients.
The Full Time Equivalent (FTE) is determined by dividing the total number of hours counselors devote to their clients by the facility ' s standard workweek of forty hours. Then, in order to obtain the facility ' s ratio, the total number of clients on the counselors ' caseload is divided by the FTE.
Staff #1 was hired as the project and facility director on January 19, 2020 and was still in this position at the time of the inspection. Staff #1 was reported to have thirty hours per week devoted to the seven clients on their caseload.
Staff #2 was hired as counselor on February 23, 2020 and promoted to a clinical supervisor on September 19, 2021. Staff #2 was reported to have twenty hours per week devoted to the six clients on their caseload.
The facility ' s caseload calculation is as follows: 50/40=1.25 (FTE); 13/1.25 = 10.4, which equals to a client/counselor ratio of 10:1.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff #1 will have 30 hours a week with clients on his caseload of 7, Staff 2# will have 20 hours with a caseload of 5, Staff# 3 assistant counselor will have 25 hours with a supervised caseload of 3.
The CFO will monitor clinical staff's caseload monthly to ensure the correct ratio is being followed.
Monitoring will be done through client file audits. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure the heaters were permanently mounted or installed in the facility.
Space heaters were discovered in two individual offices on the second floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Financial Director will ensure that no space heaters will be used within the facility and this deficiency will nor recur. Moving forward all heaters will be permanently mounted or installed in the facility. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of October 2022 through September 2023, the facility failed to provide documentation of a fire drill being conducted the month of January 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will have a overnight fire drill on 11/30/2023 to address the immediate need. The Financial Director will ensure all fire drills are logged and completed correctly to ensure the deficiencies do not recur. All day time fire drills are done on a monthly basis and all night time fire drills are completed on a per 6 month basis. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of October 2022 through September 2023, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There were three overnight fire drills conducted, but two drill logs showed that no evacuation occurred.
Overnight fire drill logs for July 2023 and September 2023 documented that no evacuation was conducted during the fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that overnight fire drills are completed at least every 6 months beginning with 12/7/2023. The facility will also ensure that during overnight fire drills, all individuals will evacuate the facility. The financial Director will ensure the deficiencies do not recur by monitoring the fire drill log each drill. |
709.22 (b) (3) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(3) Documenting the project ' s organizational structure.
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Observations
Based on a review of documentation, the governing body failed to provide documentation of the project ' s organizational structure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will provide documentation of the projects organizational structure per the departments requirements. The Assistant counselor will ensure the documentation for the organizational structure is made available and kept updated so this deficiency does not recur. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative information, the governing body failed to make complete an annual report for 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will complete the annual report to include a narrative of the companies journey on the company website. The Assistant Counselor will update the website to include the annual report to ensure the deficiency will not recur. The web page will be updated January 1, 2024. For future annual reports they will be completed at the end of each fiscal year. |
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.
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Observations
Based on review of the facility policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures. The policy and procedure manual was not annually updated by signature since October 28, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon completion of the POC in regards to the policies and procedures the Director will ensure that the proper updates and signatures are provided with the POC. The Director with the assistance of the administrative staff will annually sign and update the policies and procedures as deemed necessary. The policies and procedures will be reviewed at the end of the fiscal year. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a written procedure for documentation of discharge summaries and a procedure for clients who leave Against Medical Advice.
Based on a review of the client records, the facility failed to notify an emergency contact of a client who discharged in one applicable record.
Client # 2 was admitted on September 6, 2023 and was discharged on October 13, 2023. There was not documentation the emergency contact was notified.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The emergency contact information was added to the discharge summary form. The emergency contact will be notified within 24 hours of the client's discharge via phone call. The financial director along with the CFO will ensure that the emergency contact was notified and document whether communication was made or not.
The policies and procedures will be updated as of December 15, 2023 to include discharge summaries and list the procedure for clients who leave AMA.
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709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to provide written verification of qualifying professional credentials in one of two applicable records.
Staff #7 was hired as a technician on April 17, 2023 and was still in this position at the time of the inspection. Staff #7 ' s personnel record did not have documentation of their education or work history pertaining to their position.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward all newly hired staff will be required to submit a completed application along with all required documents. The Financial Director will ensure all paperwork is in order prior to hiring. Incomplete or missing paperwork will result in delay of start date.
Staff #7' personal record will be updated to show documentation of his education or work history pertaining to his employment record. |
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 must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to designate who is responsible for the maintenance of client records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of January 1 the policies and procedures will be updated to designate who will be responsible for maintaining client records. The Administrative Staff will be responsible for the updates in the policies and procedures, and the client records will be maintained by Administrative staff by auditing monthly. The Director will review to avoid recurring deficiencies. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a review of the facility ' s recordkeeping system, the facility failed to have a system in place to allow the identification of clients ' admissions and discharges within a specific time period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Assistant Counselor implemented a record keeping excel spreadsheet that identifies admissions and discharges of clients. The administration staff will input admission upon arrival and will add discharge within 24 hrs after client leaves. Administration staff will conduct monthly audits to ensure all records are up to date.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of a complete medication administration record (MAR) in four of four applicable records.
Client # 2 was admitted on September 6, 2023 and was discharged on October 13, 2023. Intake information indicated the client was on a medication, but no medication administration records were provided.
Client # 3 was admitted on August 2, 2023 and is still an active client. The system for recording drugs should include the date and there were two MAR sheets of PRN medications which do not include the month.
A medication prescribed to be taken 1 tab at bedtime. An August MAR includes white out for August 22, and 23. There was no additional documentation indicating a reason why the medication was not given as prescribed.
Client #4 was admitted on September 14, 2023 and is still an active client. The system for recording drugs should include the date and there were four MAR sheets of medications which do not include the month.
Client #5 was admitted on September 18, 2023 and is still an active client. The MAR for September 2023 which includes two medications.
A first medication on the MAR was prescribed to be started on September 25, 2023 and be given as follows, " Take one tablet by mouth at bedtime. "
The time given was documented as " 8A " which is not at bedtime.
There was no documentation the medication was given as prescribed on September 25, 26, 27, 28, 29, and the 30th is crossed out. There was no additional documentation indicating a reason why the medication was not given as prescribed.
There was documentation of the medication given on the 31st but September does not have 31 days.
There was documentation on the September 2023 MAR the medication was given on the 1st, 4th, 5, 6, 7, 8, and 9 but the medication was prescribed to be started on September 25, 2023.
There was no MAR for the month of October 2023.
A second medication on the MAR was prescribed to be started on September 25, 2023 and be given as follows, " Take one capsule by mouth twice daily. Complete all antibiotics " . There was no documentation the medication was given as prescribed on September 25, 26, 27, 28, and the 8A dose on the 29th. There was no additional documentation indicating a reason why the medication was not given as prescribed.
There was documentation of the medication given at 8A on the 31st but September does not have 31 days.
There was documentation on the September 2023 MAR the medication was given on the 1st, 8A on the 2nd, 8P on the 3rd, 4th, 5, 6, 7, 8, 9, and 8P on the 10th, 8P on the 11th and 8P on the 12th but the medication was prescribed to be started on September 25, 2023.
There was no MAR for the month of October 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of December 1st an individual was hired to oversee med room documentation on a weekly and monthly basis. This individual will ensure all intake information matches medication administration records, MARS sheets, PRN meds will include the month, MARS sheets will not include white-out - but will utilize a single line to note errors with staff initial, MARS sheets will include the month, medications will be given at prescribed time, MARS sheets will carry only one month with proper dates.
The staff member will do weekly inspection to ensure we are filling all guidelines. Monthly audits will be completed that all MARS and PRN sheets are following all protocols.
This staff member will report any issues to CFO.
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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to provide a written policy and procedure pertaining to the loss, theft, or misuse of drugs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Assistant counselor and the Financial Director will
will update the policies and procedures manual pertaining to the loss, theft, or misuse of drugs. Upon implementation in the policy and procedure book a copy will be posted in the med room to ensure the deficiency does not recur. The proper auditing of the med room will assure loss, theft or misuse does not occur.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure counseling services were being provided to the individual according to the treatment and rehabilitation plan in five of five client records.
All of the individual treatment plans indicated " Individual: 1x weekly, and Group: 2x daily " .
Client # 1 was admitted on February 27, 2023 and was discharged on October 5, 2023. There were no groups documented for August 9, 17, 23, September 7 and 12, 2023. Only one group per day was documented for August 10, 11, 16, 18 21, 22, 25, 28, September 1, 5, 6, 14, 15, 19, 21, 22, 26, 28. 29, October 3 and 4, 2023.
Client # 2 was admitted on September 6, 2023 and was discharged on October 13, 2023. There were no groups documented for September 19 and October 11, 2023. Only one group per day was documented for September 8, 11, 21, 26, 29, October 4, 9, 12 and 13, 2023.
Client # 3 was admitted on August 2, 2023 and is still an active client. There were no groups documented for August 3, 4, 7, 9, 10, 2023. Only one group per day was documented for August 16, 18, 21, 25, 31, September 1, 6, 7, 11, 26, 29, October 6 and 9, 2023.
Client #4 was admitted on September 14, 2023 and is still an active client. Groups 2x daily were not documented for September 18, 19, 20, 27, 28, October 9 and 10, 2023.
Client #5 was admitted on September 18, 2023 and is still an active client. Groups 2x daily were not documented for September 25, 26, October 3, 4, 9, 10 and 13, 2023. Individual sessions were not documented 1x weekly for the weeks of October 2 and 9, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Counselor created a master log sheet to log all groups that are being facilitated. This log includes:
Date
Time
Group Name
Edu or Therapeutic
Facilitator
This information will be transferred to the clients record log and filed on a monthly basis within the client file.
The CFO along with clerical staff will ensure all groups logged have a feedback form with a monthly audits a deficiency does not recur.
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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 record of service in five of five client records.
All client records reviewed failed to document a record of services provided to the client during their treatment.
Client # 1 was admitted on February 27, 2023 and was discharged on October 5, 2023. A record of service was not documented for groups from August 2 - 15, 2023. A record of service was not documented for a group on September 13, 2023.
Client # 2 was admitted on September 6, 2023 and was discharged on October 13, 2023. A record of service was not documented for groups from September 6 - 11, 2023, but group progress notes were documented for September 7, 2023 (two notes), September 8, 11, and 21, 2023.
Client # 3 was admitted on August 2, 2023 and is still an active client. A record of service was not documented for groups from August 2 - 6, August 21 - September 11, September 28 to current as of the date of the inspection, October 18, 2023. A record of service was not documented for individual sessions on August 31, September 6, 13, 20, 26, and October 6, 2023.
Client #4 was admitted on September 14, 2023 and is still an active client. A record of service was not documented for groups documented on September 14, 15, 18, 19, 28, and October 4, 2023.
Client #5 was admitted on September 18, 2023 and is still an active client. A record of service was not documented for an individual session on September 26, 2023
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Assistant Counselor created a master log sheet to log all groups that are being facilitated. This log includes:
Date
Time
Group Name
Edu or Therapeutic
Facilitator
This information will be transferred to the clients record log and filed on a monthly basis within the client file.
The client file log for individual notes will be documented and all group and individual notes will be audited by administration team monthly.
The CFO along with clerical staff will ensure all groups logged have a feedback form with a monthly audits a deficiency does not recur.
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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.
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Observations
Based on a review of personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for mandatory communicable disease training was submitted and approved by the Department for the May 17, 2023 and October 5, 2022 licensing inspections. Mandatory communicable disease training was again found to be a deficiency in the October 18-19, 2023 licensing inspection.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
Moving forward, the director, financial director, CFO, and the clerical staff will have monthly audits and we will also have random audits throughout the year to monitor the plans of correction to ensure that they are being followed so there will not be any repeated deficiencies. |