INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Genesis House - Bloomsburg 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Reports was reviewed on December 27, 2014 and re-reviewed at the time of the inspection. There are 3 different facilities contained within the project. The equivalent of 14.95 full-time counselors is employed within the project. This would require at least 1 full-time clinical supervisor. The project currently has 3 clinical supervisors, with 1 clinical supervisor at each facility in the project; however, all 3 clinical supervisors maintain a client caseload of 15 or more and devote only 20 hours per week towards clinical supervision. Therefore, the project currently does not employ one full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Board of Directors met and reviewed the DOH citations on 1/30/15. The Board of Directors and the Project Director will identify 1 full-time Clinical Director by 2/28/15 and transition the Clinical Director from their current job duties to their new job duties by 3/15/15 |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of individual training plans in one of four personnel records reviewed.
The findings include:
Four personnel records, requiring individual training plans, were reviewed on January 22, 2015. The facility did not document an individual training plan for the January 1, 2015 - December 31, 2015 training year in personnel record # 4.
Employee #4 was hired as a billing coordinator on December 27, 2011 and then hired as a counselor assistant on December 15, 2014. There was documentation of a training plan in the personnel chart for the position of billing coordinator; however, there was no documentation of an individual training plan for the position of counselor assistant for the training year 01/01/2015 - 12/31/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will ensure that all staff whom hold more than 1 job title will complete two assessments and two training plans per year rather than combining the training plan. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the fire drill logs and an interview with the project director, the facility failed to document unannounced fire drills correctly at least once per month in two of twelve months reviewed.
The findings include:
The fire drill logs were reviewed on December 27, 2014 and re-reviewed with the project director on January 22, 2015. The facility documented that fire drills were conducted on the following dates: 03/23/2014 and 07/13/2014. However, these dates are Sundays and based on the interview with the project director, the facility is not open on Sundays. The hours of operation for the facility are Monday-Thursday 9am-8pm and Fridays 9am-1pm, then from 1pm-5pm appointments only.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All fire drills are completed in the specified timeframe, however the facility director continuously gets the current date wrong. Two staff persons will now complete the fire drill log to ensure correct dates are placed on the fire drill logs. |
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 shall 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 provide clear purposes for disclosures of client identifying information for releases of information in three of ten records reviewed.
The findings included:
Ten client records requiring proper releases of information were reviewed on January 22, 2015. The facility's release of information forms used in client record #'s 3, 4, and 5 identified the following six purposes to be checked off according to the relationship of the organization:
1. To provide for ongoing efforts
2. To obtain insurance or employment of government benefits
3. To enable judges, attorneys, probation/parole officers to support treatment goals or to make legal decisions on my behalf.
4. To coordinate treatment efforts with my family/concerned persons
5. To coordinate treatment efforts with my employer
6. Other:
Client #3 was admitted to treatment on March 20, 2014 and was still an active client at time of the inspection. Two separate release of information forms to a government agency and a funding source were signed on 03/20/2014 and both consent forms had all the purposes checked, which included inconsistent reasons with the function of the recipient.
Client #4 was admitted to treatment on September 23, 2014 and was still an active client at time of the inspection. Two separate release of information forms to a government agency and a funding source were signed on 09/23/2014 and both consent forms had all the purposes checked, which included inconsistent reasons with the function of the recipient.
Client #5 was admitted to treatment on February 10, 2014 and was discharged on August 22, 2014. Two separate release of information forms to a government agency and a funding source were signed on 02/10/2014 and both consent forms had all the purposes checked, which included inconsistent reasons with the function of the recipient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. All new employees are to observe 4 initial assessments and complete paperwork with the primary therapist. 2. All new employees are to complete two assessments with a seasoned therapist to ensure they are completing all paperwork completely and ensuring the client has received proper informed consent. 3. All employees are given consent samples by the clinical director and should use as a basis for continued education and reminders. 4. All new employees will be required to attend confidentiality treatment within 6 months of their hire date and attend practical application of confidentiality within 1 year of hire date. 5. The clinical director will provide quarterly re-training on how to complete releases of information, PA 255.5 and informed consent. The clinical director will also be responsible for providing a training certificate for this training. 6. The clinical director will be responsible for reviewing all new therapist case files the day after they have completed the assessment (new employee is defined as 6 months or less of employment).
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in three of ten client records reviewed.
The findings include:
Ten client records, requiring documentation of an updated treatment plan at least every 60 days, were reviewed on January 22, 2015. The facility failed to document treatment plan updates in client records, #6, 7, and 8.
Client #6 was admitted on June 19, 2014 and was discharged on September 11, 2014. The master treatment plan was documented on June 30, 2014 and an update was due no later than August 30, 2014. There was no updated treatment plan documented in the client record as of the date of the inspection.
Client #7 was admitted on November 22, 2013 and was discharged on February 14, 2014. The master treatment plan was documented on December 11, 2013 and an update was due no later than February 11, 2014. There was no updated treatment plan documented in the client record as of the date of the inspection.
Client #8 was admitted on January 22, 2014 and was discharged on May 16, 2014. The master treatment plan was documented on January 29, 2014 and an update was due no later than March 29, 2014. There was no updated treatment plan documented in the client record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Firetree Corporate Clinical Director, with whom we contract with for services, sent out a memo in January 2014 that all staff were to not complete the treatment plan without the client, rather they were to complete the C&S and complete the treatment plan when the client did return to treatment.
The Project Director from now on will use the Corporate Clinical director for consultation of services and will check regulations and with DDAP to ensure the information being provided is accurate.
All clinical directors have been informed as of 2/10/15 to seek approval from the project director prior to changing any policy or form.
All clinical directors were informed on 1/30/15 of the change in policy and reviewed in their staff meeting with all therapists the week of 2/3/15. |