INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis House - Bloomsburg 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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709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to ensure that a complete client record was documented in three of nine client records reviewed.
The findings include:
Nine client records were reviewed for documentation of a complete client record during the renewal inspection on 12/16/15. The facility failed to document a complete client record in records, #1, 2, and 8.
Client # 1 was admitted into treatment on 12/15/14 and was still active at the time of the inspection. Progress notes documented in the client's record indicated that the client attended group counseling sessions on the following dates: 6/9/15, 9/15/15, 9/29/15, 10/6/15, 11/10/15, 11/24/15, 12/8/15, and 12/15/15. These group counseling sessions were not documented on the client's record of service. Additionally, the client's record of service indicated that the client attended individual counseling sessions on the following dates: 6/1/15, 6/15/15, 6/30/15, 7/28/15, 8/11/15, 8/25/15, and 9/8/15. The facility failed to document the provider of these individual counseling sessions on the client's record of service.
Client # 2 was admitted into treatment on 8/5/15 and was still active at the time of the inspection. A progress note documented in the client's record indicated that the client attended a group counseling session on 12/8/15. This group counseling session was not documented on the client's record of service.
Client # 8 was admitted into treatment on 6/17/15 and was discharged on 8/26/15. A discharge summary was not documented as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Directors reviewed this on 12/16/15. Erica Barnes was to review encounter forms and service logs in the staff meeting on 12/21/15, however she was ill. She reviewed the encounter logs and the service log in staff meeting on 12/28/15. The Clinical Director will review the client service logs to ensure that all services are being documented correctly. She will review the records weekly.
The new electronic system will be installed on 1/8/16 eliminating human error of missing encounters. The Clinical Director will review the EM system to ensure that the encounters are being documented appropriately through the system weekly |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in two of nine client records reviewed.
The findings include:
Four client records requiring the documentation of a physician signature on treatment plans were reviewed on 12/16/15. Treatment for these four clients were funded through the Medical Assistance program. The facility failed to obtain a physician signature on treatment plan updates for clients, # 2 and 3.
Client # 2 was admitted into treatment on 8/5/15 and was still active at the time of the inspection. A treatment plan update documented in the client's record, dated 10/21/15, was not signed by a physician.
Client # 3 was admitted into treatment on 7/10/15 and was still active at the time of the inspection. A treatment plan update documented in the client's record, dated 12/2/15, was not signed by a physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director discussed with the Clinical Director that she is now to meet with her employees for two full hours. The one hour of supervision will be used to look over files and account for paperwork.
During supervision the staff needs to bring the following to supervision: their client list, their group lists and their group notes from the following week, their calendar and their DAP notes from the following week, all their paperwork. The clinical director will review the paperwork with them at that time a give it back if it is not clinically sound. By having their calendar and client list, from week to week the clinical director can observe what clients are being discharged and what clients need treatment plan updates and C&S.
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