INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2015 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:
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection the facility failed to ensure that all fire extinguishers are inspected and approved annually.
The findings include:
A physical plant inspection was conducted on December 14, 2015. In a group counseling room, located on the 1st floor, there was a fire extinguisher tagged with an inspection date of January 2013.
The findings were discussed with staff during the licensing process.
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Plan of Correction
The Director drew a diagram of the office noting where all the fire extinguishers are placed in the facility. She placed this diagram in the kitchen of each facility on 12/18/15.
The Director will now be in charge of scheduling and being present during the inspections, to ensure that all extinguishers are inspected. Previously Firetree had been responsible for the over site of compliance. |
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.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in four of seven client records reviewed.
The findings include:
Seven client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 12/14/15. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 3, 4, and 7.
Client # 1 was admitted into treatment 6/3/15 and was still active at the time of the inspection. A comprehensive treatment plan was completed for the client on 7/8/15. The treatment plan update was not completed until 9/23/15.
Client # 3 was admitted into treatment on 2/5/15 and was discharged on 8/18/15. The last treatment plan update for the client was not completed until 5/13/15.
Client # 4 was admitted into treatment on 11/11/14 and was discharged on 7/16/15. The last treatment plan update for the client was not completed until 3/15/15.
Client # 7 was admitted into treatment on 11/19/14 and was discharged on 4/30/15. A comprehensive treatment plan was completed for the client on 12/29/14. The treatment plan update was not completed until 4/9/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director advised the clinical directors to meet with the employees for two full hour. The one hour of supervision will be used to look over files and account for paperwork.
When meeting with the staff they need to bring the following to supervision: their client list, their group lists and their group notes from the following week, their calendar and their DAP notes from the following week, all their paperwork. The clinical director can review the paperwork right there with them and give it back if it is not clinically sound. By having their calendar and client list, from week to week the clinical director can observe what clients are being discharged and what clients need treatment plan updates and C&S.
Re-training will be provided to those staff members that are confused as to how to complete treatment plans within 60 days.
The above mentioned policy was reviewed in supervision with the Clinical Directors on the week of 12/21/15. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete client record was documented in two of seven client records reviewed.
The findings include:
Seven client records were reviewed for documentation of a complete client record during the renewal inspection on 12/14/15. The facility failed to document a complete client record in records, #1 and 6.
Client # 1 was admitted into treatment on 6/3/15 and was still active at the time of the inspection. A progress note documented in the client's record indicated that the client attended a group counseling session on 12/3/15. This group counseling session was not documented on the client's record of service.
Client # 6 was admitted into treatment on 3/23/15 and was discharged on 9/23/15. A progress note documented in the client's record indicated that the client attended a group counseling session on 9/17/15. This group counseling session was not documented on the client's record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director reviewed the procedure to complete the service of record and encounter form with the staff on 12/18/15. The clinical director will review files weekly to ensure the encounter forms are being filled out correctly.
The Electronic System will be installed on 1/8/16, therefore eliminating human error of missing a group of service. The Clinical Director will review these logs to ensure that the EM system is documenting services appropriately. |