INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on April 10, 2024 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of applicable personnel records, the facility failed to document all personnel on all shifts are instructed in the use of the fire extinguishers in one of three personnel records.
Staff #1 was hired as a support staff on January 16, 2024 and still in this position at the time of the inspection. The documentation of training for being instructed in the use of the fire extinguishers was not signed or dated at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In a staff meeting held on 04/11/2024 it was discussed with the director and admin staff the importance of employees completing trainings and signing and dating all documents prior to them beginning their employment. On 04/12/2024 staff #1 reviewed, signed and dated his training during emergencies form. As of 04/12/2024 all documents including the training during emergencies for will be signed and dated. Moving forward admin staff will make sure all documents are signed and dated and in employee file. Also going forward HR will review each file for accuracy upon hire and prior to the end of each fiscal year. Corrective action completed on 04/12/2024. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of applicable personnel records, the facility failed to document all personnel on all shifts are trained to perform assigned tasks during emergencies in one of three personnel records.
Staff #1 was hired as a support staff on January 16, 2024 and still in this position at the time of the inspection. The documentation of training to perform assigned tasks during emergencies was not signed or dated at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In a meeting on 04/11/2024 it was discussed with the director and admin staff the importance of employees completing training and signing and dating all documents prior to the beginning of employment. On 04/12/2024 staff #1 reviewed, signed and dated training form for emergencies. As of 04/12/2024 all trainings and documents including the training emergencies form will be signed and dated. Moving forward admin staff will make sure all documents are signed and dated and in employee file. Going forward HR will review each file for accuracy upon hire and prior to the end of each fiscal year. Corrective action completed on 04/12/2024 |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill records, the facility failed to maintain a written fire drill record that included the exit route used and whether the fire alarm or smoke detector was operative.
Fire drill records from October 2023 through March 2024 were reviewed.
A fire drill record for January 17, 2024 did not indicate if the smoke detector or fire alarm was operational.
A fire drill record for February 19, 2024 did not indicate if the smoke detector or fire alarm was operational.
A fire drill record for March 28, 2024 did not indicate the exit route utilized during the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a meeting on 04/11/2024 with the director and admin staff it was discussed that the fire drill logs will be completed by admin staff and checked by CFO or Financial Director proceeding every drill. On 04/19/2024 a fire drill was performed, and fire drill logs was completed fully with time, dates, exit routes, smoke detector or fire alarm is operational, and the number of people that was present, location, exit areas used, the building was evacuated, and then signed by CFO with her title. Was reviewed by Financial Director. Financial director or CFO will check the log after every drill to assure everything is accurate. The CFO or Financial Director will review the logs after every drill is performed prior to placing in fire drill logbook. The plan of correction was completed on 04/19/2024. |
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.
This is a repeat citation from the October 19, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In a meeting on 04/11/2024 with the director, he was made aware that the discharge and AMA policies were missing. On 04/12/2024 the policies on discharge and AMA printed out and placed in the policies and procedures by CFO. Moving forward all changes or additions to the P&P Manual will be logged in the back of manual to assure deficiencies do not occur. The Director will review and sign the manual at the end of each fiscal year. All policy changes will be printed put into the P&P and reviewed and signed off on by the CFO or the admin staff. Plan of correction was completed on 04/12/2024 by the CFO and reviewed by admin staff. |
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 three of seven applicable records.
Client #1 was admitted on January 4, 2024 and was still an active client. A Medication Administration Record was completed for April 2024, but due to medication changes a new MAR was issued. It was dated May 2024. There was no documentation of medications given from April 5-10, 2024.
Client #6 was admitted on March 15, 2024 and discharged on March 25, 2024. Starting at admission, a medication was to be given "take 1 tablet by mouth twice daily." The MAR documented that the medication was given at 8am and 8 pm. The MAR did not document the medication was given at 8pm on March 24, 2024 and did not provide a reason that it was not given.
Client #7 was admitted on January 30, 2024 and was discharged on February 23, 2024.
Starting February 20, 2024, a medication was to be given "Take 1 tablet by mouth at bedtime...." . The MAR documented the medication was given at 8am and 8pm on February 21, 22, 23, and 24, 2024.
The client was discharged on February 23, 2024, but the MAR documented a medication was given on at 8am on February 24, 2024.
This is a repeat citation from the October 19, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a meeting with the director on 04/11/2024, he was made aware that there were issues with the MAR sheets. We will continue doing weekly overview of all MAR sheets to ensure that they are being documented correctly. We will also check all MARS sheets on a month end basis. On 04/12/2024 an addendum was added that all MAR sheets will be initialed by two staff at month end prior to placing in med file The CFO will monitor to ensure the deficiency does not recur. |
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 three of seven client records.
Client #3 was admitted on January 18, 2024 and was still an active client. A record of service entry was not documented for an individual session provided on March 15, 2024.
Client # 5 was admitted on January 2, 2024 and discharged on January 26, 2024. A record of service entry was not documented for a group session provided on January 11, 2024.
Client #6 was admitted on March 15, 2024 and discharged on March 25, 2024. A record of service entry was not documented for a group session provided on March 15, 2024.
This is a repeat citation from the October 19, 2023 licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In a meeting with the director, it was discussed that there were record of service missing in several files. Starting on 04/12/2024 a record of service will have an entry for all groups with corresponding feedbacks in date order. If absent there will be a feedback as to reasoning for absence. All group feedbacks will be filed within 7 days. All individual progress notes will be on individual client service log with progress notes filed in date order. And reviewed by admin staff. All logs will be monitored by admin staff who will sign off that all files have been audited monthly and are in correct order with all records of service forms accounted for. (Individual and group). |