INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5-6th 2019 of Good Friends, Inc by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, client record #7 was missing the name of the person/organization to whom the disclosure was made.Client Record#7 was admitted on July 31, 2018 and was discharged on November 11, 2018. A consent to release form was signed and dated on July 31, 2018 however it was missing the the name of the person/organization to whom the disclosure was made.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members will receive a review on the regulations and procedures for the correct completion of a signed consent form during upcoming scheduled department meetings. These reviews will occur with the full-time staff members on March 18, 2019 led by the Executive Director, with the Primary Therapists on March 19, 2019 led by the Clinical Director, and with the Associate Managers on March 20, 2019 led by the Executive Director. The Clinical Director will monitor form compliance through the monitoring of charts during chart review and supervision processes, beginning March 25, 2019. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, client record #7 was missing specific information to be released.Client Record#7 was admitted on July 31, 2018 and was discharged on November 11, 2018. A consent to release form was signed and dated on July 31, 2018 however it was missing the specific information that can be disclosed These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members will receive a review on the regulations and procedures for the correct completion of a signed consent form during upcoming scheduled department meetings. These reviews will occur with the full-time staff members on March 18, 2019 led by the Executive Director, with the Primary Therapists on March 19, 2019 led by the Clinical Director, and with the Associate Managers on March 20, 2019 led by the Executive Director. The Clinical Director will monitor form compliance through the monitoring of charts during chart review and supervision processes, beginning March 25, 2019. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on review of seven client records, the facility failed to document how work done by the client at the project is an integral part of his treatment and rehabilitation plan in the inital treatment plan in seven out of seven records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Initial Treatment Plan will be amended by the Clinical Director by March 18, 2019 to include the action step 1f: Client will participate in and complete house chore(s), within his ability, as scheduled. The Clinical Director, during the March 19, 2019 Clinical Staff meeting, will inform and instruct all Primary Therapists and Intake Coordinators of the change in the Initial Treatment Plan. All Initial Treatment Plans after March 22, 2019 will contain the updated material. The Clinical Director will monitor form compliance through the monitoring of charts during chart review and supervision processes, beginning March 25, 2019. |