INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 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-Harrisburg 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR,) a review of supervisory notes and staff interviews, the facility failed to provide supervision for its counselor assistants by a full-time clinical supervisor or counselor who meets the qualifications.
The Facility Director is providing supervision to both counselor assistants currently employed at this facility.
Employee #2 was hired on September 1, 2020, as the Facility Director and was still employed in this position at the time of the inspection.
Employee #5 was hired on August 21, 2023, as a Counselor Assistant and was still employed in this position at the time of the inspection.
Employee #6 was hired on August 15, 2023, as a Counselor Assistant and was still employed in this position at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
At Genesis House Inc. Harrisburg location, the clinical director who oversees the building is also the clinical supervisor.
The Hierarchy of Genesis House Inc is as follows:
Executive Director Mark Collister
Regional Clinical Director Shakeena B. Lee
Under the Executive Director and Regional Clinical Director, there are three Clinical Director who serve aa the direct clinical supervisor at each location.
The Harrisburg location, has Clinical Director Aaron Lopez who qualifies as a clinical supervisor according to § 704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of § 704.7(b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(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 specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
§ 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.
Aaron Lopez was hired January 22, 2018 initially as a Counselor Assistant. He was then promoted to a Counselor in August of 2019. Aaron was then promoted to a lead counselor in October of 2020. Aaron was then promoted to Clinical Director in July of 2023. Aaron's educational background includes Alvernia/BA/ Behavioral Health/2016 and he completed Clinical Supervision Training provided by DDAP February 19, 2021.
Genesis House Inc. has taken a look further into this and is going to have a Lead Counselor hired, that will be able to act as a clinical supervisor, as of October 31, 2023. This will be in addition to the Clinical Director.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative documents and an interview with facility staff, the project director, failed to annually update and sign a written manual delineating project policies and procedures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to annually update and sign a written manual delineating project policies and procedures.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and ensuring that policy and procedure are up to date and in line with DDAP requirements. As policies and procedures are reviewed, updated, and changed, the Executive Director/Regional Clinical Director, will be signing off that each one and proceed annually updating and signing the written manual delineating our policies and procedures. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in six out of eight records reviewed.
Client #1 was admitted on January 31, 2023, and was still active at the time of the inspection. The treatment plan was dated February 20, 2023.
Client #2 was admitted on January 18, 2023, and was still active at the time of the inspection. The treatment plan was dated February 2, 2023.
Client #3 was admitted on April 20, 2023, and was still active at the time of the inspection. The treatment plan was dated June 1, 2023.
Client #5 was admitted on March 8, 2023 and was discharged on December 11, 2023. The treatment plan was dated February 6, 2023.
Client #6 was admitted on April 12, 2023 and was discharged on August 7, 2023. The treatment plan was dated May 12, 2023.
Client #7 was admitted on May 13, 2023 and was discharged on June16, 2023. The treatment plan was dated April 4, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Throughout treatment at Genesis House Inc., support services are identified and documented in the client file (i.e. biopsychosocial, relapse prevention plan, and during the initial intake assessment). Genesis House Inc., will provide a retraining to all Genesis House Inc. employees by January 31, 2024, to ensure staff are documenting supports and supportive services directly in the Treatment Plan.
The Regional Clinical Director will collaborate with the Director of Training to provide training to all clinical staff members on documentation and treatment planning.
Each facility's clinical director to ensure this training takes place during individual supervision, group supervision, and/ or staff meetings.
Each clinical director will then be responsible to collaborate with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria.
When a deficiency is identified, the Clinical Director of the facility will work with the clinician to get the appropriate information corrected in the treatment plan for the following review.
The clinician will then be responsible for making the corrections and informing the clinical director for review and approval.
The clinical director will follow up with the Compliance and Program Development Coordinator to ensure follow through and documentation completed by all clinicians meets criteria. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of eight records reviewed. The facility's policy states that case consultations must be completed, at minimum, monthly.
Client #1 was admitted on January 31, 2023, and was still active at the time of the inspection There was only case consultation, dated January 31, 2023, documented in the client record.
Client #2 was admitted on January 18, 2023, and was still active at the time of the inspection. There was only one case consultation, January 18, 2023, documented in this client record.
Client #3 was admitted on April 20, 2023, and was still active at the time of the inspection. There was only one case consultation, dated April 20, 2023, documented in this client record.
Client #4 was admitted on May 22, 2023, and was still active at the time of the inspection. There was only one case consultation, dated May 22, 2023, documented in this client record.
Client #5 was admitted on March 8, 2023, and was discharged on September 11, 2023. There were two case consultations, dated March 8, 2023, and September 11, 2023, documented in this client record.
Client #6 was admitted on April 12,2023 and was discharged on August 7, 2023.There were two, case consultations, dated April 12, 2023 and August 7, 2023, documented in this client record.
Client #8 was admitted on March 27, 2023, and was discharged on August 7, 2023. There were two case consultations, dated March 27, 2023, and August 7, 2023, documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy states that case consultations must be completed, at minimum, monthly.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and ensuring that policy and procedure are up to date and in line with DDAP requirements. As policies and procedures are reviewed, updated, and changed, the Executive Director/Regional Clinical Director, will be signing off that each one and proceed annually updating and signing the written manual delineating our policies and procedures.
The current policy on Case Consultation is currently under review/revision at this time and is projected to be completed by December 31, 2023.
Genesis House will then ensure that the new policy and procedure is distributed to all staff for training and review to be completed by January 31, 2024.
Clinical Directors will then document when completing case consultation with clinicians and keep record for review. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of two applicable discharged record reviews.
The facility's policy notes that follow-up will be completed on each discharged client using phone calls and mailed follow up forms upon 3 months, 6 months, and 1 year after discharge.
Client #6 was admitted on April 12, 2023, and was discharged on August 7, 2023. There was no documentation of a follow-up phone call or letter in the client ' s record.
Client #8 was admitted on March 27, 2023 and was discharged on August 7, 2023.There was no documentation of a follow-up phone call or letter in the client's record.
This is a repeat citation from the October 26, 2021 and October 12, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to provide a complete client record, which is to include follow-up information in two out of two applicable discharged record reviews.
The facility's policy notes that follow-up will be completed on each discharged client using phone calls and mailed follow up forms upon 3 months, 6 months, and 1 year after discharge.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and ensuring that policy and procedure are up to date and in line with DDAP requirements. As policies and procedures are reviewed, updated, and changed, the Executive Director/Regional Clinical Director, will be signing off that each one and proceed annually updating and signing the written manual delineating our policies and procedures.
The current policy on follow-up, is currently under review/revision at this time and is projected to be completed by December 31, 2023.
Genesis House will then ensure that the new policy and procedure is reviewed and signed off on by the Executive Director, distributed to all staff for training, and review to be completed by January 31, 2024.
Genesis House Inc's. Compliance and Program Development Coordinator will be reviewing client charts and completing a clinical audit tool on a monthly basis. In addition, the Clinical Director's will then be responsible for added oversight with the clinical staff that follow up's are being completed as a part of their discussions during supervision.
Follow-ups will be documented in the electronic record of each client. |
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 the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on October 26, 2021 and October 12, 2022, addressing the requirement that 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 follow-up information.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to comply with plans of correction approved by the Department.
As of July 31, 2023, Genesis House Inc., has hired a Compliance and Program Development Coordinator. The job duties of this person also include quality assurance and the review of client files.
The Compliance and Program Development Coordinator will be responsible for completing chart audits throughout the month each month, to assure charts are up to regulatory standards. |