INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14, 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 lnc. 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 fire drill logs from October 2021 through October 2022, the facility failed to conduct an unannounced drill during the month of December 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Genesis House, Inc. failed to conduct unannounced fire drills during the month of December 2021.
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.
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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 seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five client records reviewed.
Client #1 was admitted on March 7, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 20, 2022 and the next update was due no later than July 20, 2022; however, the update wasn ' t documented in the client record until July 29, 2022
Client #2 was admitted on December 21, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 30, 2022 and the next update was due no later than August 30, 2022; however, there was no update documented until September 8, 2022.
Client #3 was admitted on February 11, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 15, 2022 and the next update was due no later than June 15, 2022; however, there was no update documented until June 30, 2022.
Client #4 was admitted on January 31, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 5, 2022 and the next update was due no later than June 5, 2022; however, there was no update documented until August 2, 2022.
Client #5 was admitted on May 25, 2021 and was discharged on June 15, 2022. A treatment plan update was completed on October 25, 2021 and the next update was due no later than December 25, 2022; however, no update was documented until January 31, 2022.
These findings were discussed with the facility staff during the licensing process.
This is a repeat citation from the October 20, 2021 licensing inspection.
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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)(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 outpatient client records, the facility failed to document and compete follow up information in one of three applicable client records reviewed.
Client #7 was admitted on February 1, 2022 and was discharged on September 9, 2022. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing process.
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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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