INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports was reviewed on December 27, 2014 and re-reviewed at the time of the inspection. There are 3 different facilities contained within the project. The equivalent of 14.95 full-time counselors is employed within the project. This would require at least 1 full-time clinical supervisor. The project currently has 3 clinical supervisors, with 1 clinical supervisor at each facility in the project; however, all 3 clinical supervisors maintain a client caseload of 15 or more and devote only 20 hours per week towards clinical supervision. Therefore, the project currently does not employ one full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Board of Directors met and reviewed the DOH citations on 1/30/15. The Board of Directors and the Project Director will identify 1 full-time Clinical Director by 2/28/15 and transition the Clinical Director from their current job duties to their new job duties by 3/15/15. |
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 the facility ' s Staffing Requirements Facility Summary Report (SRFSR), the facility failed to provide documentation of HIV/AIDS and TB/STD training.
The findings include:
The SRFSR was reviewed on December 27, 2014 and re-reviewed on January 21, 2015. The facility ' s SRFSR listed 1 clinical staff person as not having the required HIV/AIDS and TB/STD training, #4.
Employee #4 is a counselor and was hired on October 24, 2013. HIV/AIDS training and TB/STD training were due to be completed no later than October 24, 2014. There was no documentation of HIV/AIDS training and TB/STD training on the SRFSR form or in the counselor's personnel file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility policy for new hire is as such: employee will complete a training needs assessment and a training plan on hire date. The employee and the clinical director are given a copy of his or her training plan and is set up with a DDAP user name and password to register for core training classes. The employee is responsible for completing his or her required trainings within the required time period. The Project Director reviewed the training plan and completion of trainings quarterly and furnishes continued needs to the employee and the clinical director.
The Project Director, will develop a written policy in regards to completion of mandatory trainings; the employees will sign the policy which will state all the new hire required trainings and timeframes, and all requirements for further CUE's. The policy will include disciplinary action including termination if the employee does not complete the required trainings within the mandated time period. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions could not be seen outside the counseling room in one of two group counseling rooms inspected.
The findings include:
The physical plant inspection took place on January 21, 2015 at around 2:00 pm. During the inspection of the large group room, the Licensing Specialist observed the only window in the room which had sheer, see-through curtains as the only window treatment. The large group room is located on the ground floor, thus enabling an individual to see into the group room from outside of the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director purchased non sheer window treatments on 1/30/15 and replaced the existing window treatments on 2/3/15. |