INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2021 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the project fiscal management, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities for the fiscal year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to complete it's fiscal audit within the timeframe as prescribed by DDAP regulations.
Genesis House, Inc. will secure the services of a different independent fiscal auditor for 2021, thereby avoiding a future delays in completion of our annual fiscal audit moving forward. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on two of five applicable personnel records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluation being reviewed and signed by the employee being evaluated.
Employee # 6 was hired as a counselor on September 7, 2013 and was still in this role at the time of the inspection. An annual written staff performance evaluation was provided however, the evaluation was not signed by the employee.
Employee # 7 was hired as a counselor on July 2, 2015 and was still in this role at the time of the inspection. An annual written staff performance evaluation was provided however, the evaluation was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc failed to provide an individual staff performance evaluation that was acknowledged and signed by the employee.
Genesis House, Inc. will designate our Administrative Assistant to monitor and track all staff performance evaluations moving forward to ensure compliance. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency, or organization to whom the disclosure is being made.
Client # 2 was admitted on April 28, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 28, 2021 to a funding source did not provide the name of the person, agency, or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House's Training Director will retrain all staff in regards to the appropriate completion of consent forms. This training will include the completion of how to review a consent form with a client, through the use of role play, visual assistance, and how to appropriately complete a consent form. Training Director and Clinical Directors will conduct frequent random samples of consent forms in order to monitor for compliance and will address accordingly. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 2 was admitted on April 28, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 28, 2021 to a funding source did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House's Training Director will retrain all staff in regards to the appropriate completion of consent forms. This training will include the completion of how to review a consent form with a client, through the use of role play, visual assistance, and how to appropriately complete a consent form. Training Director and Clinical Directors will conduct frequent random samples of consent forms in order to monitor for compliance and will address accordingly. |
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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 2 was admitted on April 28, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 28, 2021 to a funding source did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the December 3, 2019 annual inspection.
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Plan of Correction
Genesis House's Training Director will retrain all staff in regards to the appropriate completion of consent forms. This training will include the completion of how to review a consent form with a client, through the use of role play, visual assistance, and how to appropriately complete a consent form. Training Director and Clinical Directors will conduct frequent random samples of consent forms in order to monitor for compliance and will address accordingly. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on seven of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client but instead had "SET" which stands for signed electronic telehealth.
Client # 1 was admitted on May 18, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 18, 2021 to a funding agency, "other" funding agency, case manager, bail officer, and emergency contact and dated June 17, 2021 to a case manager did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 2 was admitted on April 28, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 29, 2021 to a case manager and therapist, on May 6, 2021 to an "other agency" and a case manager, and on July 20, 2021 to a physician did not have a valid signature by the client but instead had "SET" in the signature line. Also, an informed and voluntary consent from the client for the disclosure of information dated April 28, 2021 to a funding agency had no signature by the client.
Client # 3 was admitted on April 26, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated April 26, 2021 to a funding agency, a transportation company dated May 17, 2021 and an emergency contact and dated April 28, 2021 did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 4 was admitted on March 30, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated March 30, 2021 to a funding agency, parole officer, and an emergency contact did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 5 was admitted on June 2, 2020 and was discharged on March 18, 2021. An informed and voluntary consent from the client for the disclosure of information dated February 23, 2021 to a funding agency and case manager and to an emergency contact dated February 24, 2021 did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 6 was admitted on November 16, 2020 and was discharged on March 20, 2021. An informed and voluntary consent from the client for the disclosure of information dated November 16, 2020 to a funding agency and an emergency contact did not have a valid signature by the client but instead had "SET" in the signature line.
Client # 7 was admitted on July 28, 2020 and was discharged on July 18, 2021. An informed and voluntary consent from the client for the disclosure of information dated July 28, 2021 to a funding agency, probation officer, case manager, and an emergency contact did not have a valid signature by the client but instead had "SET" in the signature line.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House reviewed this direction from DDAP inspector immediately, as this was a misunderstanding that with tele services being permitted due to the pandemic that we were able to use SET. This understanding was identified via MCOs and OMHSAS. Genesis House polices have been adjusted to require that all initial appointments are completed in person, to avoid the use of SET on documentation in which verbal consent cannot be used, specifically consent forms. If someone is unable to make arrangements to attend an initial assessment in person, the location Clinical Director will be notified in order to determine an individualized plan to meet that individual's needs. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include documentation if a copy of the consent was offered to the client.
Client # 2 was admitted on April 28, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to include documentation if a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House's Training Director will retrain all staff in regards to the appropriate completion of consent forms. This training will include the completion of how to review a consent form with a client, through the use of role play, visual assistance, and how to appropriately complete a consent form. Training Director and Clinical Directors will conduct frequent random samples of consent forms in order to monitor for compliance and will address accordingly. |
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 four of seven client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days.
Client # 1 was admitted on May 18, 2021 and was still active at the time of the inspection. A treatment plan update occurred on June 17, 2021. The next treatment plan update occurred on October 14, 2021 but was due to occur no later than August 17, 2021.
Client # 4 was admitted on March 30, 2021 and was still active at the time of the inspection. A treatment plan update occurred on June 21, 2021. The next treatment plan update occurred on September 15, 2021 but was due to occur no later than August 21, 2021.
Client # 5 was admitted on June 2, 2020 and was discharged on March 18, 2021. A treatment plan occurred on August 30, 2020. The next treatment plan update occurred on December 21, 2020 but was due to occur no later than October 21, 2020.
Client # 7 was admitted on July 28, 2020 and was discharged on July 18, 2021. A treatment plan update occurred on January 16, 2021. The next treatment plan update occurred on April 24, 2021but was due to occur no later than March 16, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House Clinical Directors will review in staff meeting the policy related to treatment plans needing to be updated every 60 days. As a team, we will have discussions regarding barriers to meet these requirements and problem solve together as to how to overcome these barriers. Individual clinicians who struggle especially with this area, will be provided additional direction and support in individual supervision. This will continue to be monitored through regular file reviews. |