INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 2024, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from January 2024 through September 2024, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of August 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.28(d)(1) Fire Safety ? Monthly Fire Drills
- Deficiency: Facility did not conduct unannounced fire drills in August 2024.
- Corrective Action Plan:
o Schedule Compliance: Implement a monthly calendar reminder for unannounced fire drills, ensuring drills are conducted consistently.
o Audit Process: Facility director will review fire drill logs monthly to ensure no months are missed.
o Completion Date: Effective immediately, with the next audit scheduled by the end of each month.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs from January 2024 through September 2024, the facility failed to document the date that fire drills were completed. The fire drill logs noted that drills were completed; however, there was no documentation of the dates for the months of: January, February, March and June.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
705.28(d)(4) Fire Safety ? Documentation of Fire Drill Dates
- Deficiency: Fire drill logs lacked dates for January, February, March, and June.
- Corrective Action Plan:
o Log Enhancement: Update fire drill logs to include a checklist ensuring required details (date, time, evacuation time, exit route, number of occupants, problems encountered, alarm/smoke detector status) are fully documented.
o Staff Training: Train all responsible staff on the importance of comprehensive log documentation.
o Completion Date: Immediate, with compliance reviews scheduled monthly.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2024 through September 2024, the facility failed to prepare alternative exit routes to be used during fire drills. The logs noted that only the "side" exit was used for all documented drills.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.28(d)(5) Fire Safety ? Alternate Exit Routes for Drills
- Deficiency: Only the "side" exit was used for all fire drills, without alternate routes.
- Corrective Action Plan:
o Emergency Exit Plan Update: Revise emergency protocols to include alternate exit routes for fire drills and assign responsibility for coordinating varied exit routes monthly.
o Documentation: Ensure all future fire drills document the chosen exit route, with the goal of alternating routes monthly.
o Completion Date: Effective immediately, with compliance to be monitored starting from the next fire drill.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs from January 2024 through September 2024, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill. The facility reported that it was sounding an alarm in an alternative way due to them being housed in a multi-use building. The facility doesn't have an approved exception for this regulation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
705.28(d)(7) Fire Safety ? Activation of Fire Alarm or Smoke Detector
- Deficiency: Facility did not document activation of fire alarms or smoke detectors due to multi-use building restrictions, and no exception was documented.
- Corrective Action Plan:
o Regulatory Compliance: Apply for an approved exception with the Department of Drug and Alcohol Programs, documenting alternative notification methods used during fire drills.
o Documentation Update: Until the exception is approved, ensure that fire drill logs clearly note the alternative method used in place of the alarm system.
o Completion Date: Exception request to be submitted within two weeks; immediate documentation of alternative methods in place.
The request for an exception was filed the day of the inspection and a response was received from DDAP on October 25, 2024 stating that the exception was approved. |
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 obtain a completed informed and voluntary consent which included the name of the person, agency or organization to whom disclosure is made in one out of eight records reviewed.
Client #5 was admitted on April 29, 2024, and was still active at the time of the inspection. This record contained a consent to release information form, dated April 29, 2024, that did not document to whom the information was supposed to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.28(c)(1) Confidentiality ? Client Consent for Information Disclosure
Deficiency: Incomplete consent form for Client #5, missing the recipient of the information disclosure.
Corrective Action Plan:
Form Review: Conduct a full audit of current client consent forms to ensure all required fields are complete. This task is to be completed by the Clinical Director of the Harrisburg Office during the chart audits
Standard Operating Procedure Update: Update procedures to include a double-check of consent forms for completeness during intake. This task will be completed in tandem with the entire management team Clinical Director's, Regional Clinical Director, and Executive Director.
Completion Date: Immediate for current clients; audit to be completed within two weeks.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to ensure written documentation that individual treatment and rehabilitation plans were developed with the client, within the first three sessions per facility policy, in four out of seven records reviewed.
Client #2 was admitted on December 27, 2023 and discharged on August 26, 2024. A treatment and rehabilitation plan dated Janaury 2, 2024 did not include documentation that it was developed with the client.
Client #4 was admitted on June 26, 2024 and still active at time of inspection. A treatment and rehabilitation plan was due to be completed by the third session on July 10, 2024; however, there was no written documentation it was developed with the client until October 7, 2024.
Client #5 was admitted on April 29, 2024 and still active at time of inspection. A treatment and rehabilitation plan was due to be completed by the third session on May 7, 2024; however, there was no written documentation it was developed with the client prior to the date of the inspection.
Client #7 was admitted on April 29, 2024 and still active at time of inspection. A treatment and rehabilitation plan was due to be completed by the third session on June 4, 2024; however, there was no written documentation it was developed with the client until August 13, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(a) Treatment and Rehabilitation Services ? Documentation of Treatment Plan Development
- Deficiency: Lack of written documentation showing treatment plans were developed with clients within the required timeframe.
- Corrective Action Plan:
o Policy Enforcement: Reinforce the policy that treatment plans must be completed with client involvement by the third session.
o Documentation Protocol: Implement a checklist for counselors to verify the client's participation in treatment planning.
o Staff Training: Conduct a refresher training on timely documentation of client collaboration in treatment planning.
o Completion Date: Immediate implementation of checklist; training to be completed within two weeks.
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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 three out of eight records reviewed. The facility's policy and procedures manual states a case consultation will be completed within 30 days of admission and within 30 days of discharge from the program.
Client #2 was admitted on December 27, 2023, and was discharged on August 26, 2024. There was no discharge case consultation documented in the client record.
Client #3 was admitted on admitted on September 28, 2023, and discharged on February 2, 2024. There was no discharge case consultation documented in the client record.
Client #5 was admitted on April 29, 2024, and was still active at the time of the inspection. There was no admission case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.93(a)(8) Client Records ? Case Consultation Documentation
- Deficiency: Lack of documented case consultations within the facility's required 30-day period for three clients.
- Corrective Action Plan:
o Compliance Audits: Conduct a monthly audit of active and discharged client records to ensure case consultations are completed within the specified timeframe.
o Training and Reminders: Remind counselors of the importance of timely documentation of both admission and discharge consultations per facility policy.
o Completion Date: Audits to begin immediately, with reminders issued and initial training review to occur within the next week.
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