INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2 and 3, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on December 28, 2008.
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Plan of Correction
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709.23(b)(2) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(2) Written reports of project operations.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document current board meeting minutes.
The finding include:
A review of the facility's policy and procedure manual and an interview conducted on December 3, 2008 with the Project Director confirmed that the facility could not produce current board of director meeting minutes for the last 12 months.
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Plan of Correction
Project director reviewed the standard with the governing body on 12/8/08 during the weekly directors meeting to ensure their understanding. Governing body agreed to provide the project director with appropriate board meeting minutes for all subsequent board meetings on 12/8/08. Project director will place the board meeting minutes in the facility's policy and procedure manual for the departments review upon receipt. Project director will monitor to ensure appropriate compliance by 12/31/08. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedure on client confidentiality and a review of the facility's HIPAA Right to Privacy Notice, the facility failed to include correct reference to 4 Pa. Code Subsection 255.5. The information provided in the HIPAA Right to Privacy Notice misinformed clients receiving drug and alcohol treatment services of their rights and protections regarding the confidentiality of any information which would identify them as a participant in drug and alcohol treatment services.
The findings include:
A thorough review of the facility's confidentiality policy and procedure regarding client records on December 2-3, 2008, revealed that the policy and procedure did not include reference to 4 Pa. Code Subsections 255.5 (a)(1) through 255.5 (c) as required.
The facility's HIPAA Right to Privacy Notice failed to inform clients that releases without client consent permitted under the HIPAA regulations may still be prohibited by state law and regulation and by federal regulation at 42 CFR Part 2. The HIPAA Right to Privacy Notice did not include any disclaimer for drug and alcohol treatment records.
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Plan of Correction
Project director will revise the facility's current confidentiality policy by 12/15/08 to address the correct reference to PA Code Subsection 255.5. Project director will secure board approval for the revised policy and add to the facility's policy and procedures manual by 1/5/09. Facility director will review the revised policy with the facility staff on 1/7/09 to ensure their understanding.
Project director met with the governing body on 12/8/08 to address the issue of the Hipaa privacy notice. Project director will create a confidentiality form on 12/15/08 and submit for board approval by 1/5/09. The new confidentiality form will address the disclaimer relating to the state and federal confidentialiy laws and the Hipaa form. Facility director will review new confidentiality form with the facility staff on 1/7/09 to ensure their understanding. New form will be provided to the facility's clients in conjunction with the Hipaa privacy notice and each will be placed in the client files. Facility director will monitor on a weekly basis during weekly client chart reviews by 1/31/09 to ensure appropriate compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility did not document complete drug and alcohol histories in ten of fourteen client records.
The findings include:
Fourteen client records were reviewed on December 2 and 3, 2008. Thirteen were required to have complete Drug and Alcohol histories. Client records # 1, 2, 3, 4, 6, 7, 8,10, 11, 12, 13 and 14, 12 of 13 applicable client records, contained Drug and Alcohol histories which did not include lengths and patterns of drug and alcohol usage.
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Plan of Correction
Facility director will retrain all facility staff on the appropriate completion of the facility's health questionnaire form, focusing on the lengths and patterns of the client substance consumption within the client drug and alcohol history section, at the weekly staff meeting on 12/10/08. Facility director will monitor weekly during clinical client chart reviews by 12/31/08 to ensure apporpriate compliance. |
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 the review of client records, the facility failed to document complete treatment plans .
The findings include:
Fourteen client records were reviewed on December 2 - 3, 2008. Five of ten client records did not include documentation of complete treatment plans. There was no documentation of a treatment plan in client record #1. Four client records, # 2, 4, 11 and 12, did not include documentation of the proposed type of support services offered to the client as part of the comprehensive treatment planning process.
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Plan of Correction
Facility director will retrain all facility staff on the apporpriate completion of the facility's treatment planning processes, focusing on the timeliness of completion and the documentation of support systems utilized, at the weekly staff meeting on 12/10/08. Facility director will monitor weekly during the client chart reviews by 12/31/08 to ensure appropriate compliance. |
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 fourteen client records and an interview with the facility director, the facility failed to follow up on each discharged client.
The findings include:
Fourteen client records were reviewed on December 2 and 3, 2008. Eight of these client records were required to have documented follow up contacts in the record. Five client records, # 6, 7, 11, 13 and 14, did not have documentation of the facility's attempts to follow up on those clients. As the result of an interview with the facility director during the inspection, it was determined that follow up attempts do not occur for adolescent clients referred from a local shelter due to the policies of the shelter in regard to leaving forwarding addresses of clients referred elsewhere subsequent to the completion of their Drug and Alcohol treatment. At least one follow up attempt for each discharged client must be documented.
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Plan of Correction
Facility director will retrain all facility staff on the appropriate completion of the facility's follow up processes at the weekly staff meeting on 12/10/08. Facility director will monitor weekly during the weekly client chart reviews by 12/31/08 to ensure appropriate compliance. Project director will contact the residential adolescent facility on 12/12/08 to attempt to obtain permission to secure client contact information upon discharge to enable the appropriate compliance with this standard. |