INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 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, 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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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 October 2023 through September 2024, the facility failed to prepare alternative exit routes to be used during fire drills. The logs noted that only the "front" 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
- Deficiency: Fire drill logs from October 2023 through September 2024 documented only the "front" exit, without alternate routes.
- Corrective Action Plan:
o Exit Plan Update: Establish a rotating schedule of alternate exit routes for monthly fire drills.
o Documentation Compliance: Ensure logs clearly indicate the exit route used for each drill, alternating monthly between all available routes.
o Completion Date: Effective immediately; monitored monthly to ensure compliance.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information which is to include date, event, or condition upon which the consent will expire, in one out of seven records.
Client #3 was admitted on February 6, 2024 and was still an active client at the time of the inspection. Two consent forms, dated February 6, 2024, for an funding source and a government agency, did not specify an expiration date or event.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
. 709.28(c)(6) Confidentiality ? Consent Expiration Date
- Deficiency: Missing expiration date or event on consent forms for Client #3 regarding disclosure to a funding source and a government agency.
- Corrective Action Plan:
o Form Update: Modify consent forms to require an expiration date or event before signing, with fields highlighted as mandatory.
o Staff Training: Conduct a training session for staff on confidentiality requirements, including the necessity of expiration dates on all consent forms.
o Completion Date: Effective immediately, with training completed within one week.
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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 a proposed type of support service on individual treatment plans in three out of seven records reviewed.
Client #1 was admitted on January 20, 2024, and was still active at the time of the inspection. There were no support services documented on the client's February 22, 2024, comprehensive treatment plan.
Client #3 was admitted on February 6, 2024, and was still active at the time of the inspection. There were no support services documented on the client's February 28, 2024, comprehensive treatment plan.
Client #4 was admitted on January 9, 2024 and was discharged on April 11, 2024. There were no support services documented on the client's January 18, 2024 comprehensive treatment plan.
This is a repeat citation from the September 22, 2023 licesing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92(a)(3) Treatment and Rehabilitation Services ? Support Services Documentation
- Deficiency: Three client treatment plans lacked documentation of proposed support services.
- Corrective Action Plan:
o Form Revision: Update treatment plan templates to include a mandatory section for proposed support services.
o Staff Training: Train counselors on the importance of including support services in each treatment plan.
o Audit Process: Conduct monthly reviews of treatment plans to ensure support services are documented.
o Completion Date: Immediate implementation; training completed within two weeks and monthly audits ongoing.
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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 review and update treatment and rehabilitation plans at least every sixty days in five out of seven records reviewed.
Client #1 was admitted on January 20, 2024, and was still active at the time of the inspection. A treatment plan update was completed on August 8, 2024, and the next update was due no later than October 8, 2024; however, there were no additional updates documented in the client record.
Client #2 was admitted on February 22, 2024, and was still active at the time of the inspection. A comprehensive treatment plan update was completed on March 4, 2024, and the next update was due no later than May 4, 2024; however, it was completed on May 7, 2024. Additionally, the next update was due no later than July 7, 2024; however, it was completed on July 9, 2024.
Client #3 was admitted on February 6, 2024, and was still active at the time of the inspection. A treatment plan update was completed on March 28, 2024, and the next update was due no later than May 28, 2024; however, it was completed on June 18, 2024.
Client #4 was admitted on January 9, 2024, and was discharged on April 11, 2024. A comprehensive treatment plan was completed on January 18, 2024, and the next update was due no later than March 18, 2024; however, there were no additional updates documented in the client record.
Client #6 was admitted on February 19, 2024, and was discharged on May 16, 2024. A comprehensive treatment plan was completed on March 4, 2024, and the next update was due no later than May 4, 2024; however, there were no additional updates documented in the client record
This is a repeat citation from October 20, 2021, October 14, 2022 and September 22, 2023 licesing renewal inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92(b) Treatment and Rehabilitation Services ? Review and Update of Treatment Plans
- Deficiency: Treatment plans were not reviewed and updated every 60 days as required, resulting in repeat citations from past inspections.
- Corrective Action Plan:
o Automated Reminders: Implement automated reminders within the facility's record-keeping system to alert counselors to upcoming 60-day reviews.
o Accountability Measures: Counselors will confirm completion of treatment plan reviews, with supervisors performing monthly audits.
o Staff Retraining: Reinforce the importance of 60-day updates to all clinical staff.
o Completion Date: Automation and audits to begin immediately, with all staff retrained within two weeks.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in four out of seven charts reviewed.
Client #1 was admitted on January 20, 2024, and was still active at the time of the inspection. An updated treatment plan completed on August 8, 2024, indicated the client was to receive one individual and two group sessions per week. During the weeks of September 8-14, and September 22-28, 2024, no individual sessions were documented in the client record.
Client #2 was admitted on February 22, 2024, and was still active at the time of the inspection. An updated treatment plan completed on July 9, 2024, indicated the client was to receive two individual sessions per month and one group session per week. During the week of July 28-August 3, 2024, no group sessions were documented in the client record.
Client #3 was admitted on February 6, 2024, and was still active at the time of the inspection. An updated treatment plan completed on June 18, 2024, indicated the client was to receive one individual and one group session per week. During the week of August 4-10, 2024, no group sessions were documented in the client record.
Client #6 was admitted on February 19, 2024, and was discharged on May 16, 2024. A comprehensive treatment plan completed May 4, 2024, indicated the client was to receive one individual and one group session per week. During the weeks of April 14-20, and April 21-27, 2024, no individual sessions were documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92(c) Treatment and Rehabilitation Services ? Counseling Services Consistency
- Deficiency: Documented counseling services did not consistently align with treatment plans.
- Corrective Action Plan:
o Session Verification: Implement a weekly checklist for counselors to ensure all planned sessions (individual and group) align with each client's treatment plan.
o Audits: Supervisors will conduct weekly audits of session documentation against treatment plans, addressing any discrepancies promptly.
o Completion Date: Weekly audit implementation effective immediately, with the first full compliance audit within one week.
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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 that were approved by the Department.
A plan of correction for the requirement that treatment and rehabilitation plans shall be reviewed and updated at least every 60 days were submitted and approved by the Department for September 22, 2023, October 14, 2022 and October 20, 2021 annual licensing inspections. Treatment plan updates was again found to be a deficiency in the October 9, 2024 licensing inspection. ,
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.17(a)(3) Failure to Comply with Plan of Correction ? Treatment Plan Updates
- Deficiency: Noncompliance with previously approved plans of correction related to treatment plan updates every 60 days.
- Corrective Action Plan:
o Enhanced Monitoring: Establish a dedicated compliance team responsible for monitoring adherence to all corrective actions and state regulations, with bi-weekly progress reports.
o Policy Review: Conduct a comprehensive policy review on treatment plan updates, incorporating additional accountability measures to prevent future lapses.
o Report to Department: Submit quarterly compliance reports to the Department of Drug and Alcohol Programs to demonstrate ongoing adherence to corrective actions.
o Completion Date: Monitoring team in place immediately; policy review and enhanced procedures fully implemented within 30 days.
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