INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12, 2022, 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 the October 2021 through September 2022 fire drill records, the facility failed to conduct unannounced drills during the month of January 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 26, 2021 licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to conduct unannounced fire drills during the month of January 2022.
Genesis House, Inc. will train/retrain all new and existing employees on the proper fire emergency evacuation process and compliance of unannounced monthly fire drills and documentation of event.
Clinical Directors will monitor monthly for regulatory compliance. |
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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in six of seven applicable client records reviewed.
Client #1 was admitted on January 4, 2022 and was still active at the time of the inspection. A treatment plan update was completed on August 1, 2022, and the next update was due no later October 1, 2022; however, there was no update documented in the record at the time of the inspection.
Client #2 was admitted on January 13, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 5, 2022, and the next update was due no later than September 5, 2022; however, there was no update documented in the record until October 6, 2022.
Client #3 was admitted on April 18, 2022 and was still active at the time of the inspection. A treatment plan update was completed on August 1, 2022, and the next update was due no later than October 1, 2022; however, there was no update documented in the record until October 12, 2022.
Client #4 was admitted on May 4, 2022 and was still active at the time of the inspection. A treatment plan update was completed on August 11, 2022, and the next update was due no later than October 11, 2022; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on December 31, 2021 and was discharged on August 29, 2022. A treatment plan update was completed on March 1, 2022, and the next update was due no later than May 1, 2022; however, there was no update documented in the record until May 24, 2022.
Client #7 was admitted on February 15, 2022 and was discharged on July 18, 2022. The comprehensive treatment plan was completed on February 15, 2022, and the next update was due no later than April 15, 2022; however, there was no update documented in the record until May 16, 2022.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from the October 26, 2021, November 19, 2019, and December 18, 2017 licensing inspections.
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Plan of Correction
Genesis House, Inc. failed to document treatment plan updates within the regulatory timeframe.
Genesis House, Inc. will train/retrain all new and existing clinical employees on the importance of, and regulatory expectations of treatment plan updates on or before 60 days of the initial treatment plan.
All clinical supervisors will monitor treatment plan update timelines using a clinical documentation audit tool. This tool will provide clinical staff the needed information to maintain documentation compliance.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one of the three applicable client records reviewed.
Client #5 was admitted on June 1, 2021 and was discharged on August 30, 2021. There was not documentation of an aftercare plan being completed in the client record.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from the October 26, 2021 licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to provide a complete client record, which is to include an aftercare plan.
Genesis House, Inc. has identified in the electronic medical record a limitation which prevents clinical staff the ability to indicate aftercare required option at time of successful discharge.
Medical records software technicians have been notified of limitations and will rectify identified limitations to ensure compliance with regulatory requirements. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include documentation of follow up information in one of the three applicable client records reviewed.
Client #5 was admitted on June 1, 2021 and was discharged on August 30, 2021. There was not documentation of follow up being completed in the client record.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from the October 26, 2021 licensing inspection.
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Plan of Correction
Genesis House, Inc. failed to document post discharge follow up within the regulatory timeframe.
Genesis House, Inc. will train/retrain all new and existing clinical employees on the importance of, and regulatory expectations of post discharge follow up.
All clinical supervisors will monitor post discharge follow up timelines using a clinical documentation audit tool. This tool will provide clinical staff the needed information to maintain documentation compliance.
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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 a review of seven client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting fire drills was submitted and approved by the Department for the October 26, 2021 annual licensing inspection. Completing and documenting fire drills was again found to be a deficiency in the October 12, 2022 licensing inspection.
A plan of correction for completing and documenting treatment plan updates for the outpatient records was submitted and approved by the Department for the October 26, 2021, August 5, 2020, and November 20, 2019 annual licensing inspections. Completing and documenting treatment plan updates was again found to be a deficiency in the October 12, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to comply with plans of correction that were approved by the Department.
Genesis House, Inc. leadership will review immediately all identified plans of correction with all Genesis House employees to ensure understanding of all agency policy/procedures and adherence to all DDAP regulatory expectations, which will be monitored by using informal internal audit tools and monthly review of all procedures during employee supervision.
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