INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8 - 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of policy and procedures, the facility failed to provide documentation of the governing body approval of the written staff compliance plan. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director held a meeting on November 6,2020. Going forward the Genesis House Ministries, inc governing body shall approve a written compliance plan to ensure that the staff persons affected by this regulation meet the appropriate educational and experiential qualifications and receive training as stipulated in the regulations.
Each written compliance plan will be approved by the governing body.
The Director will monitor that these are complete. This correction will be completed by November 25, 2020 |
704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of administrative information, the facility failed to ensure the clinical supervisor met the qualifications for the position.Employee # 2 was hired for the position of clinical supervisor on March 23, 2020. Documentation provided was for a Master ' s degree of Organizational Leadership which does not qualify employee #2 for the clinical supervisor position.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director had a meeting with the Clinical Director on November 6, 2020.
The Clinical Director sent for a copy of her qualifications for the Clinical Director position on November 8, 2020. We are awaiting the arrival of these documents. We will forward them to DDAP as soon as we receive them. Going forward all persons hired will meet the qualifications of the respective position and the Director will monitor that these corrections are complete. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of administrative information, the facility failed to provide monthly documented meetings between the clinical supervisor, and their supervisor.Employee # 2 was hired for the position of clinical supervisor on March 23, 2020. Documentation of the first six months of meetings was not provided.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director held a meeting on November 6 to discuss plan of Correction. The Director will have monthly meetings with the Clinical Supervisor and these meetings will be documented and kept on file. The Director will monitor that these corrections are implemented. This corrective action was implemented on 11/12/2020. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative information, the facility failed to document an overall plan for addressing staff training needs for the 2020 training year. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a comprehensive staff development program for agency personnel including policies and procedures for program indicating who is responsible and the time frames for completion. Also an overall plan for addressing these needs. The project director will document this plan by filling out annual forms for each employee. This plan of correction was discussed in a meeting on November 6, 2020. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of administrative information, the facility failed to provide documentation of CPR certification and First Aid training for residential treatment staff # 1, 3, 4, 5, and 6. The facility did not have at least one person trained in these skills onsite during the project's hours of operation. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director had a meeting with the staff discussing this on November 6, 2020. The facility staff had the training complete already, but was awaiting the certificates. These Certificates will be sent to DDAP on November 12, 2020. Going forward training plans will be completed and proper qualifications will be obtained. We will have at least one person certified in CPR on site at all times. The Director will monitor the completion of these corrections |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative information, the facility failed to conduct monthly fire drills. The facility was approved to begin providing services in January 2020. As of August 2020, no fire drills have been documented. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with the staff on November 6, 2020. The facility will conduct unannounced monthly fire drills starting November 11, 2020. These fire drills will be documented by the staff on duty. The Director will monitor that the correction has been made. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of administrative information, the facility failed to conduct fire drills during sleeping hours. The facility was approved to begin providing services in January 2020. As of August 2020, no fire drills during sleeping hours have been documented. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with staff on November 6, 2020. The staff on duty will conduct Overnight fire drills starting November 26, 2020 and will continue to do them every six months. These fire drills will be documented. Director will monitor these corrections. |
709.22 (b) (1) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(1) Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
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Observations
Based on a review of policy and procedures, the facility governing body failed to designate the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held on November 11, 2020 to discuss this issue. The Governing body will provide proof that the Project Director was appointed by the governing body. This proof will be in the form of a letter and kept in the Policy and Procedure Manual. |
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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to disclosure of information in four of four clients records reviewed.Client # 1 was admitted on April 20, 2020 and discharged on September 23, 2020. Information was disclosed to a judge.Client # 2 was admitted on August 20, 2020 and discharged on September 17, 2020. A release of information was signed on August 20, 2020 but failed to indicate the specific information to be disclosed, the purpose of the disclosure, and a copy of the consent was offered to the client.Client #3 was admitted on March 16, 2020 and discharged on September 17, 2020. Information was disclosed to a Probation office.Client # 4 was admitted on March 9, 2020 and discharged on March 24, 2020. Information was disclosed to another provider.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with the clinical staff on November 6, 2020 to discuss this matter. The clinical staff such as intake director, counselor and case manager will have a release of information form signed and contained in client record. This form will be filled out for any and all information disclosed to any third party. This form will indicate the specific information to be disclosed and the purpose of the disclosure and a copy of the consent will be offered to the client. These releases will be kept in the client file. The Director will monitor that the correction has been made. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that the project may not discriminate in the provision of services on the basis of ethnicity, and color in all six records reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director had a meeting to correct this on November 6, 2020. The case manager updated the clients rights form to include ethnicity and color. All clients records were updated with the correct form and a copy was offered to each client. The Director will monitor that the correction has been made. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client, and reasons for removing sections shall be documented in the record in all six records reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held on November 6, 2020 to discuss this matter. The clients rights form was updated in this meeting so that it states that the project, facility or clinical director may temporarily remove portions of the record prior to the inspection by the client, and reasons for removing sections. This made aware to each client by having them fill out a new clients rights and a copy was put in each client record and offered to each client. The Director lead this meeting and will also monitor that the correction has been made. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have the right to appeal a decision limiting access to their records to the director in all six records reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director held meeting on November 6, 2020 With the clinical staff to fix this issue. In this meeting the Case manager update the clients rights form. The form was updated to say that the client has a right to appeal a decision limiting access to their records to the director. This form was shown to all clients and signed by them a copy was put in the client file and offered to each client. The Director will monitor that the correction has been made |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in all six records reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held by the Director to address this issue on November 6, 2020. The case manager updated the clients rights form in this meeting. The form now says that the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. Each client signed off on this new form and the client file was updated and offered to the client. Director will monitor that the correction has been made. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have the right to submit rebuttal data or memoranda to their own records in all six records reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held by the Director to address this issue on November 6,2020. The case manager updated the clients rights form in this meeting, The form now says that the client has the right to submit a rebuttal data or memoranda to their own records, Each client signed off on this new form and the client file was updated and offered to the client. The Director will monitor that the correction has been made. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical exam per the facility policy and procedure in four of six client records. Client records #2, #4, #5 and #6 failed to document a physical exam.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director held a meeting on November 6, 2020 to discuss this issue. Intake will ask for a physical from the prospective client that is no longer than six months old, If client does not have one or can not obtain one the Genesis House Ministries, Inc will contact the contracted physicians office and schedule a physical within the first 48 hours, but no later than 7 days after entry. This physical will be documented and kept in the client file. The Director will monitor that this correction has been made. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 per the agency policy and procedure in in four of six client records. Client records #1, #2, #4, and #6 failed to document a psychosocial evaluation.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held by the Director on November 6, 2020 to discuss this issue with the clinical staff. The counselor will document a psychosocial evaluation per the agency policy and procedure in the first 10 days of admission into the program. This documentation will be kept in the client file. The Director will monitor this correction has been made. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan per the agency policy and procedure in six of six client records. All client records reviewed failed to document a preliminary treatment plan.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held by director and clinical staff to discuss this issue on November 6, 2020. The counselor will document a preliminary treatment plan on the first day of treatment following intake. The patient will sign off on this plan and this plan will be kept in the client file. The Director will monitor that this correction has been made. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan per the agency policy and procedure in six of six client records. All client records reviewed failed to document an individual treatment plan.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held by the director with the clinical staff to address this issue on November 6, 2020. The counselor will develop with the client a individual treatment and rehabilitation plan and this plan will be documented and kept in the client file, The Director will monitor that this correction has been made. |
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 record of service per the agency policy and procedure in six of six client records. All client records reviewed failed to document a record of service.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was discussed in a meeting held by the director and clinical staff on November 6, 2020. The counselor and group facilitator will fill out the record of service for an individual and group sessions.This form was put into action on November 9, 2020. These records will be kept in the client file. The Director will monitor that this correction has been made. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes per the agency policy and procedure in six of six client records. All client records reviewed failed to document progress notes.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was discussed by the director in a meeting with the clinical staff on November 6, 2020. The Counselor will document progress notes after every session with the client. These notes will be kept in the client file. The Director will monitor that this correction has been made. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation per the facility policy and procedure in three of three applicable client records. Client records #1, #3, and #6 failed to document a case consultation.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was addressed by the director to the clinical staff on November 6, 2020. The counselor will document the case consultation notes once every 90 days as noted in our policy and procedures. The Director will monitor that these corrections are made. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan per the facility policy and procedure in two of two client records. Client records #1, and #3 failed to document an aftercare plan.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was addressed in a meeting held by the director with the clinical staff on November 6, 2020. The counselor will document an aftercare plan on each client. This plan will be put into the clients file. The Director will monitor that these corrections are made. |
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 per the agency policy and procedure in in four of six client records. Client records #1, #2, #3, and #4 failed to document a discharge summary.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held on November 6, 2020 by the director to discuss this issue with the clinical staff. The counselor will prepare a discharge summary for the client and place in the clients file.The discharge summary will Brief description of reason for discharge to include whether it was a successful completion of program or not. Also if client was transferred to another facility will be included. This will be noted in the file. The Director will monitor that these correction are made. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a follow-up per the facility policy and procedure in one of one client records. Client record #4 failed to document a follow-up.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was address on November 6, 2020 in a meeting held by the director with the clinical staff. Clients referred to other resources or facilities will be monitored by a follow up call by the counselor within 7 days of arrival. Transfer and referral patients will be contacted by their counselor 30 days post transfer. This will be documented and kept in client file. The Director will monitor that these correction are made. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document the verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in six of six client records. All client records reviewed failed to document this verification.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This issue was addressed by the director in a clinical staff meeting on November 6, 2020. The clinical staff will document all work done by the client at the project. One of the ways this will be done is to fill out a record of service for each client and treatment plan. The Director will monitor that this correction has been made. |