INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2015 by staff from the Division of Drug and Alcohol 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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709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to demonstrate efforts towards allowing clients to revoke authorization of consent, in accordance with 45 CFR 164.508 (b)(5) and 42 CFR 2.31 (a)(8), in two of five client records reviewed.
The findings include:
Five client records requiring informed and voluntary consent to release information forms were reviewed on 12/15/15. The facility failed to demonstrate efforts towards allowing clients to revoke authorization of consent, in accordance with 45 CFR 164.508 (b)(5) and 42 CFR 2.31 (a)(8), in client records # 2 and 5.
Client # 2 was admitted into treatment on 10/7/15 and was discharged on 12/9/15. The client's record contained a consent to release information to a law enforcement agency (probation), which was signed and dated on 10/7/15. The consent form specified that the consent would remain in effect and could not be revoked by the client until the maximum date of the client's sentence.
Client # 5 was admitted into treatment on 3/25/15 and was discharged on 7/15/15. The client's record contained a consent to release information to a law enforcement agency (probation), which was signed and dated on 3/25/15. The consent form specified that the consent would remain in effect and could not be revoked by the client until the maximum date of the client's sentence.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent in regards to this citation, is a consent that was created by the previous director for DOC clients. The release did not allow clients to revoke authorization of consent.
On 12/15/15 the Director informed all the staff that the release of information (standard document that was created in 2001 for DOC/State Parole)
must be removed from all files and replaced with the regular consent that we use. The Director explained the problem with this consent as written, it states that the client CANNOT revoke the consent at any time.
The Clinical Director is responsible to ensure understanding and to review again with the staff in staff meeting. The clinical Director is also responsible for reviewing all files to ensure the release was removed from the client file. She will do this by 1/10/16.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to demonstrate efforts towards informing clients of their client rights and documenting written acknowledgment by clients that they have been notified of those rights in one of five records reviewed.
The findings include:
Five client records were reviewed on 12/15/15. All clients receiving drug and alcohol treatment are required to be informed of their rights. A client rights form is presented to all clients for signature, to document written acknowledgement by clients that they have been notified of those rights. However, the facility failed to document written acknowledgement of the notification of client rights in client record # 3.
Client # 3 was admitted into treatment on 4/9/15 and was still active at the time of inspection. The facility failed to document written acknowledgement by the client that they have been notified of their rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/16/15 the Lead Counselor reviewed client chart #3 with the staff person.
On 12/18/15 The Director reviewed with the staff intake procedures and the necessity of reviewing these forms (client rights) with clients and ensuring their understanding.
On 12/18/15 the Director reviewed with the clinical directors the new policy to review all new client charts with staff to ensure that all procedures are being completed in a timely fashion. Staff will bring all charts to individual supervision for review starting 12/18/15 and continue ongoing.
Re-training by the Clinical Director will take place for those whom are found to miss signatures and review. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two of five records reviewed.
The findings include:
Five client records were reviewed on 12/15/15. All records were reviewed for a psychosocial evaluation. A psychosocial evaluation was not documented in client records # 2 and 5.
Client # 2 was admitted into treatment on 10/7/15 and was discharged on 12/9/15. A psychosocial evaluation was not documented in the client's record as of the date of the licensing inspection.
Client # 5 was admitted into treatment on 3/25/15 and was discharged on 7/15/15. A psychosocial evaluation was not documented in the client's record as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff all know and have been trained on how to complete assessments in a timely fashion.
On 12/15/15 the Director reviewed with the clinical directors the action required each week in supervision to ensure that case management tasks are being completed:
1. U until we all get EM, I the Clinical Director must 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 you meet with your 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 is responsible to 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 they can observe what clients are being discharged and what clients need treatment plan updates and C&S.
In supervision with the clinical directors on the week of 12/21/15 the Director reviewed the above mentioned policy again.
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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 five of five client records reviewed.
The findings include:
Five client records were reviewed for documentation of a complete client record during the renewal inspection on 12/15/15. The facility failed to document a complete client record in records # 1, 2, 3, 4, and 5.
Client # 1 was admitted into treatment on 9/24/15 and was still active at the time of the inspection. The facility failed to document a record of service that specified the services provided to the client.
Client # 2 was admitted into treatment on 10/7/15 and was discharged on 12/9/15. The facility failed to document a record of service that specified the services provided to the client.
Client # 3 was admitted into treatment on 4/9/15 and was still active at the time of the inspection. The facility failed to document a record of service that specified the services provided to the client.
Client # 4 was admitted into treatment on 3/31/15 and was discharged on 7/14/15. The facility failed to document a record of service that specified the services provided to the client.
Client # 5 was admitted into treatment on 3/25/15 and was discharged on 7/15/15. The facility failed to document a record of service that specified the services provided to the client. Additionally, the record of service for the client indicated the client attended a treatment session on 6/10/15. However, a progress note for this treatment session was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director reviewed with all staff as of 12/15/15 they will use the sign/in cross encounter form. The form was reviewed with each staff member and examples of how to complete the log were given to each staff member. The clinical director is responsible to ensure that the staff are using the new form and also responsible to ensure that they complete the form correctly.
The Director then reviewed this with each staff person again on 12/21/15.
Weekly review of charts will help ensure this is being done by the Clinical Director. Previously this facility used flow sheets that had to be documented by the clinical director which caused a back log in information.
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