INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 17, 2023 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 and personnel records, the facility failed to document that each staff member providing clinical services met the qualifications for the position of counselor in three of eight client records.Client records # 1, 2, and 3 contained group therapy notes in which a support staff was facilitating therapeutic groups. Staff #4 was hired as a support staff member on January 19, 2020. Therapeutic group notes were documented by staff #4. The facility did not provide documentation Staff #4 met the educational and experiential requirements for the position of counselor.This was reviewed with the facility staff during the licensing process.This is a repeat citation from the October 5, 2022 annual licensing inspection.
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Plan of Correction
Upon review staff will no longer run therapeutic groups and only run educational groups as of 5/18. Moving forward the facility director will monitor group notes to ensure correct documentation, as well as noting that only counselors will be the ones facilitating therapeutic groups. |
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 had completed HIV/AIDS and TB/STD training within the required timeframe in one of five staff records.Staff #4 was hired as a support staff member on January 19, 2020. The TB/STD training was to be completed by January 19, 2022. There was no documentation this training was completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from October 5, 2022 annual licensing inspection.
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Plan of Correction
Staff #4 completed TD/STD training on 12.7.22, documentation was added to staff records on 5.24.23. The Assistant Director will ensure that all training is completed and filed appropriately. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made on consent to release information forms in two of eight client records. Client #1 was admitted on April 3, 2023 and still active at the time of the inspection. An informed and voluntary consent for a funding source was signed and dated March 1, 2023, but did not include the name of the person, agency, or organization to whom the disclosure is made.Client #7 was admitted on February 27, 2023 and was still active at the time of the inspection. An informed and voluntary consent for a funding source was signed and dated March 1, 2023, but did not include the name of the person, agency, or organization to whom the disclosure is made.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 signed updated releases for funding on 5.24.23.
Our facility is now going to implement approved internal forms for all releases of information. The CFO will do file audits to ensure releases are being utilized and completed appropriately. POC date is 5.24.23.
Client #7 signed updated releases for funding on 5.24.23.
Our facility is now going to implement approved internal forms for all releases of information. The CFO will do file audits to ensure releases are being utilized and completed appropriately. POC date is 5.24.23. |
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 disclosed on consent to release information forms in one of eight client records. Client #2 was admitted on February 8, 2023 and was still active at the time of the inspection. An informed and voluntary consent was signed on February 9, 2023. This consent stated, " all information in Genesis House Ministries file " , and did not identify the specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from October 5, 2022 and October 29, 2021 annual licensing inspections.
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Plan of Correction
Client #2 signed updated releases for funding on 5.24.23.
Our facility is now going to implement approved internal forms for all releases of information. The CFO will do file audits to ensure releases are being utilized and completed appropriately. POC date is 5.24.23. |
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 disclosure on the consent to release information form in one of eight records.Client #7 was admitted on February 27, 2023 and was still active at the time of the inspection. An informed and voluntary consent for a funding source was signed and dated March 1, 2023 but did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from October 5, 2022 and October 29, 2021 annual licensing inspections.
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Plan of Correction
Client #7 signed updated releases for funding on 5.24.23.
Our facility is now going to implement approved internal forms for all releases of information. The CFO will do file audits to ensure releases are being utilized and completed appropriately. POC date is 5.24.23. |
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 specific information disclosed to be included on consent forms was submitted and approved by the Department for the October 5, 2022 and October 29, 2021 annual licensing inspections. Specific information disclosed on the consent form was again found to be a deficiency in the May 17, 2023 licensing inspection.A plan of correction for the purpose of disclosure to be included on consent forms was submitted and approved by the Department for the October 5, 2022 and October 29, 2021 annual licensing inspections. The purpose of disclosure on consent forms was again found to be a deficiency in the May 17, 2023 licensing inspection.This was reviewed with the facility staff during the licensing process.This is a repeat citation from the October 5, 2022 annual licensing inspection.
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Plan of Correction
Facility Director will meet with staff to review Policies and Procedures concerning information required on releases and as well as qualifications for therapy. The CFO and supporting staff will monitor these through file audits. These audits will be discussed in our staffing meetings to ensure all areas are being addressed and completed appropriately. POC date is 6/19/23. |