INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10-11, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Good Friends, 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that stored frozen food was kept at or below a temperature of 0 degrees Fahrenheit. The findings include:A physical plant inspection was conducted on March 11, 2016. The inspection of the food storage areas found that a freezer showed a temperature higher than 0 degrees Fahrenheit. The freezer, located in the kitchen, showed the temperature to be at 8 degrees. A review of the freezer log showed that this freezer was above 0 degrees daily during the time period of 1/1/2016 - 3/11/2016. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On Monday, March 14, 2016, our external freezer repairman conducted an on-site review of the freezer, altering mechanical mechanisms to produce a temperature of zero degrees. Our maintenance employee will monitor the temperature on a daily basis, documenting such on the freezer log sheet. If the temperature exceeds the required temperature he will contact the external repairman for service. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.The findings include:A physical plant inspection was conducted on March 11, 2016. A fire extinguisher located in a counselor's office on the 2nd floor was last inspected in September 2011. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On March 14, 2016 our Executive Director contacted our external fire extinguisher company to schedule the inspection and update of this sole extinguisher. On March 14, 2016, a new fire extinguisher was purchased by our maintenance employee. This new extinguisher was placed in the counselor's office to allow for safety while the outdated extinguisher was removed, awaiting inspection and updating. |
709.53(a) LICENSURE Complete Client Record
709.53. 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 on an individual which included information relative to the client's involvement with the project was documented in five of ten client records reviewed.The findings include:Ten client records were reviewed for documentation of a complete client record during the renewal inspection on March 10-11, 2016. The facility failed to document a complete record in client records # 1, 4, 7, 9, and 10Client # 1 was admitted into treatment on 1/29/16 and was still active at the time of the inspection. The record of service for the client indicated that the client attended a group counseling session on 2/23/16. A progress note for this group counseling session was not documented in the client's record. Additionally, a progress note in the client's record indicated that the client attended a group counseling session on 2/22/16. This group counseling session was not documented on the client's record of service. Client # 4 was admitted into treatment on 2/12/16 and was still active at the time of the inspection. The record of service for the client indicated that the client attended a group counseling session on 2/23/16. A progress note for this group counseling session was not documented in the client's record. Additionally, a progress note in the client's record indicated that the client attended a group counseling session on 2/22/16. This group counseling session was not documented on the client's record of service. Client # 7 was admitted into treatment on 11/24/15 and was discharged on 2/19/16. The record of service for the client indicated that the client attended a group counseling session on 2/9/16. A progress note for this group counseling session was not documented in the client's record. Client # 9 was admitted into treatment on 8/3/15 and was discharged on 11/13/15. The record of service for the client indicated that the client attended group counseling sessions on 8/25/15, 10/6/15, and 11/3/15. Progress notes for these group counseling sessions were not documented in the client's record. A progress note in the client's record indicated that the client attended a group counseling session on 8/24/15. This group counseling session was not documented on the client's record of service. The record of service indicated that the client attended an individual counseling session on 11/10/15. A progress note for this individual counseling session was not documented in the client's record. Lastly, a progress note documented in the client's record indicated that the client attended an individual counseling session on 11/12/15. This individual counseling session was not documented on the client's record of service. Client # 10 was admitted into treatment on 9/22/15 and was discharged on 12/7/15. The record of service for the client indicated that the client attended an individual counseling session on 11/25/16. A progress note for this individual counseling session was not documented on the client's record of service. A progress note documented in the client's record indicated that the client attended an individual counseling session on 11/24/16. This individual counseling session was not documented on the client's record of service. The client's record of service indicated that the client attended group counseling sessions on 10/13/15 and 11/25/15. Progress notes for these group counseling sessions were not documented in the client's record. Lastly, progress notes documented in the client's record indicated that the client attended group counseling sessions on 10/14/15 and 11/24/15. These group counseling sessions were not documented on the client's record of service. These findings were reviewed with facility staff during the licensing process. This is a repeat citation, as the facility was cited for non-compliance of this standard during the previous licensing renewal inspection on February 18-19, 2015.
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Plan of Correction
On April 5, 2016, during a Clinical Staff meeting, the Clinical Director will review with all clinical staff members the specifics of this deficiency. The Clinical Director will discuss the need to be more cautious when completing the record of service form to be consistent with the recorded documentation from various types of sessions/encounters. The Clinical Director will review the need to record any missed appointments in the client record of service as well as the timely filing of any clinical notes/material. The Clinical Director will monitor compliance through monthly record reviews. |