INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2019 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 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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704.7(b) LICENSURE Counselor Qualifications
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.
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Observations
During a licensing inspection and personnel record review conducted on November 19, 2019, employee # 3 and employee # 4 were unable to meet the qualifications of a counselor to include one year of clinical experience upon hire.
Employee # 3 was hired on January 22, 2018 as a counselor assistant and promoted to a counselor on July 23, 2018. The employee was promoted prior to one year of clinical experience.
Employee # 4 was hired as a counselor on January 2, 2018. After review of resume and work experience, it was determined prior experience was not in a clinical setting.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director changed the job description on 11/19/2019 to include the terminology of the definition of clinical setting or experience to reflect the information provided in this inspection. All employee's whom where hired since 2014 were reviewed to ensure accuracy. Emergency management meeting was held on 11/19/2019 at 5 PM to review this information with the entire management team. All applicants must meet the description of clinical setting in order to be considered for the position of counselor.
The Director will personally oversee hiring and promotion of counselors and counselor assistant staff as of 11/19/2019 to ensure that staff are following the policies of promotion of counselor assistants and hiring counselors that meet the qualifications. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
During a licensing inspection conducted on November 19, 2019, the facility failed to provide documentation of a counselor assistant receiving at least one hour of direct observation during the supervised period.
Employee # 3 was hired as a counselor assistant on January 22, 2018 and promoted to a counselor on July 23, 2019. During employee supervision period as a counselor assistant, there was no documentation of direct observation in the employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director and RCD met on 11/19/2019 at 4 PM to review this citation. The RCD supervises the CD whom supervises the employees at this location. As of 11/19/2019, the RCD will review all counselor supervision logs once a month to ensure that proper documentation is taking place. On 11/19/2019, the Director had an emergency meeting with all the managers to review this citation. The director reviewed the polices again with each manager. on 11/20/2019 the Director added a form to the new hire orientation plan for the clinical director to review, which includes providing proof of at least 2 hours per week of direct observation. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on November 19, 2019, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The licensing alert had been approved by DDAP Director, Patrica De Leo on 1/19/2017. Upon clarification during this inspection that other policies addressing this procedure is not sufficient, Director of Outpatient Services updated the policy on 11/15/2019. Policy was sent to all facility directors and clinical directors on 11/15/2019. Policy was reviewed with all staff on 11/18/19 by the staffing direct supervisor. The policy was placed in the P/P paper manual and in the Public Drive for staff to view. |
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
During a licensing inspection conducted on November 19, 2019, the facility failed to document treatment and rehabilitation plan updates within the regulatory timeframe in three client records reviewed.
Client # 2 was admitted on January 10, 2019 and was discharged on October 28, 2019. A treatment and rehabilitation plan update was completed on February 8, 2019 and the next update was completed on May 8, 2019. A treatment and rehabilitation plan update was due no later than April 8, 2019; however, there was no update documented in the record at the time of the inspection.
Client # 3 was admitted on November 8, 2018 and was discharged on March 11, 2019. A treatment and rehabilitation plan update was due no later than January 29, 2019; however, there was no update documented in the record at the time of the inspection
Client # 5 was admitted on May 23, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan update was due no later than October 19, 2019; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director requested on 11/26/2019 from owner to add a red flash on the screen 10 days prior to client treatment plan being due. Currently the ER only creates a task in the task board and staff have not found it to be helpful. Training for all clinical staff on 12/6/2019, review the necessity of completing treatment plans and how to do the treatment plan update on time. RCD and CD will check five charts per week to assess improvement in this area as of 11/20/2019. |