INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4-5, 2022 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of client records, the facility failed to document that each staff member providing clinical services met the qualifications for the position of counselor in six of six client records.Client records # 1, 2, 3, 4, 5 and 6 contained group therapy notes in which a support staff were facilitating the groups. The support staff that were facilitating the groups did not meet the educational and experiential qualifications for the position of counselor.Two staff that were facilitating therapy groups did not provide documentation that they met the educational and experiential requirements for the position of counselor.Staff #4 is a support staff that was hired on December 1, 2017. Per staff interview, Staff #4 holds a high school diploma and does not have any clinical experience.Staff #5 is a support staff that was hired on December 11, 2019. Per staff interview, Staff #5 holds a GED certificate and does not have any clinical experience.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Only qualified staff will facilitate and document therapeutic groups according to client staff ratio. The Director will monitor all groups and documentation. The POC will be implemented as of 11/23/2022. |
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 staff records, the facility failed to document that staff completed TB/STD and HIV/AIDS training within the required timeframe in four of four staff records.Staff #1 was hired as the project / facility director on January 19, 2020. HIV/AIDS and TB/STD training was due to be completed by January 19, 2022. There was no documentation that staff #1 completed HIV/AIDS training.Staff #2 was hired as a clinical supervisor on September 16, 2021. HIV/AIDS and TB/STD training was due to be completed by September 16, 2022. There was no documentation that staff #2 completed TB/STD training and the HIV/AIDS training documented was only for one hour.Staff #4 was hired as a support staff on December 1, 2017, prior to the facility being licensed by DDAP. The DDAP license was effective on January 29, 2020. HIV/AIDS and TB/STD training was due to be completed by January 29, 2022. There was no documentation that staff #4 completed HIV/AIDS training.Staff #5 was hired as a support staff on December 11, 2019, prior to the facility being licensed by DDAP. The DDAP license was effective on January 29, 2020. HIV/AIDS and TB/STD training was due to be completed by January 29, 2022. There was no documentation that staff #5 completed HIV/AIDS or TB/STD training.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff #1 has TB/STD/Hepatitis virtual training as of 6/21/2022, will complete HIV/AIDS by December 7, 2022
Staff #2 Clinical Supervisor has completed
5.75 hours of HIV/AIDS training
Diagnosis and Early Stages - 1.0 - 11/8/2021
Understanding the illness 1.0 - 11/10/2021
Beyond Basics 1.25 - 11/19/2021
Baic HIV 1.25 - 11/19/2021
Risk of HIV, HIV, Hepatitis and other infectious diseases 1.25 - 11/15/2022
The additional HIV/AIDES and TB/STD will be completed by December 7, 2022.
Staff #4 completed TB/STD 4 hour virtual training on 6/21/2022
HIV/AIDS training will be completed by December 7, 2022.
Staff #5 will have HIV/AIDES and TB/STD by December 7. 2022
All documentation will be filed in the employee files.
Moving forward, all current and future employees will complete the required TB/STD and HIV/AIDS trainings within the required timeframe.
Human Resource Director will monitor to ensure all trainings are implemented.
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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 documentation, the facility failed to document, and make public, an annual report for 2021 which included the names of officers, directors and principal shareholders.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Board Members, Director and CFO have been added to the public website. The annual report along with the officers and Directors will be made available to the public upon request.
The HR Director and Financial Director will make sure the deficiency does not recur, and will implement the POC by 1/16/2023. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the facility failed to complete an annual financial audit for 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A letter of exemption was sent certified mail on 11/14/2022 in accordance with and are subject to 28 PA.code 709.25(a).
Requesting an exemption for the audit, as we did not meet the income threshold.
If the exception request is not approved, we will complete the 2021 financial audit.
The Financial Director and Director will work together to implement and monitor this plan of action. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on the signed consents documented in four of six client records. Client #1 was admitted on January 31, 2022 and discharged on July 31, 2022. Two signed consents documented in client record #1 did not include the specific information to be released.Client #2 was admitted June 7, 2022 and discharged on June 27, 2022. One signed consent documented in client record #2 did not include the specific information to be released.Client #4 was admitted on August 11, 2022 and is currently an active client. Two signed consents documented in client record #4 did not include the specific information to be released.Client #5 was admitted on July 13, 2022 and is currently an active client. One signed consent documented in client record #5 did not include the specific information to be released.These findings were reviewed with facility staff during the licensing process.This is a repeat deficiency from the October 29, 2021 annual licensing inspection.
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Plan of Correction
Moving forward we will document the specific information disclosed on signed consent forms. The Director will monitor this on a monthly basis. This will be implemented on 11/16/2022. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the consent on the signed consents documented in four of six client records. Client #1 was admitted on January 31, 2022 and discharged on July 31, 2022. Four signed consents documented in client record #1 did not include the purpose of the disclosure.Client #2 was admitted June 7, 2022 and discharged on June 27, 2022. Ten signed consents documented in client record #2 did not include the purpose of the disclosure.Client #3 was admitted on November 21, 2021 and discharged on May 16, 2022. Fifteen signed consents documented in client record #3 did not include the purpose of the disclosure.Client #6 was admitted on August 11, 2022 and is currently an active client. Four signed consents documented in client record #6 did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.This is a repeat deficiency from the October 29, 2021 annual licensing inspection.
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Plan of Correction
We will document the purpose of disclosure on each client signed consent forms. The director is responsible for the implementation and will review the purpose of disclosure each month to make sure they are being filled out properly. We will have this implemented by 1/16/2023 |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of client records, the facility failed to file a written unusual incident report with the Department within three business days following an unusual incident involving an outbreak of a contagious disease requiring CDC notification.Client #6 was admitted on June 14, 2022 and is still active client. An incident occurred on July 7, 2022, but there was no documentation an unusual incident report was filed with the Department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward we will report within 3 days any unusual incident involving an outbreak of contagious disease that require CDC notification to the DDAP website.
The Director will be responsible to implement and monitor this plan of correction
The implementation date was
11/16/2022 |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates, at least every thirty days, in two of five client records.Client #1 was admitted on January 31, 2022 and discharged on July 31, 2022. The last treatment plan update was documented on May 31, 2022. There were no treatment plan updates documented for the months of June or July 2022.Client #5 was admitted on July 13, 2022. There was a treatment plan dated July 13, 2022 and an update dated September 11, 2022. There were no treatment plan updates documented for the month of August 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat deficiency from the October 29, 2021 annual licensing inspection.
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Plan of Correction
The corrected documentation for treatment plans will be reviewed and updated every thirty days by the Director to be sure all treatment plans are completed. This POC will be implemented by January 16, 2023. |
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 complete record of service in six of six client records.Client records #1-6 did not include documentation of a record of service which documented individual therapy. These findings were reviewed with facility staff during the licensing process.This is a repeat deficiency from the October 29, 2021, and the October 8 - 9, 2020 annual licensing inspections.
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Plan of Correction
Each client record shall include documentation of record services that were provided.
This will be implemented and monitored by the Director to be sure it does not recur. The POC is January 16, 2023. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in one of three client records.Client #2 was admitted to treatment on June 1, 2022 and discharged on June 27, 2022. There was no documentation of a discharge summary in client record #2.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All discharged client records will have documentation of a discharge summary. The Director will be responsible for implementing and monitoring this plan of correction. It will be monitored by reviewing the files upon discharge. This POC was implemented as of 11/16/2023. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for the client Record of Service was submitted and approved by the Department for the October 29, 2021 and October 8-9, 2020 annual licensing inspections. The client Record of Service was again found to be a deficiency in the October 4-5, 2022, annual licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction is to implement all of the corrections and services by the dates provided to be sure all guidelines are being brought into compliance.
The Director will be responsible for implementing and monitoring all of the plans of correction on an ongoing basis to assure the corrective actions are implemented by January 16, 2023 |