INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28-29, 2012 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the water temperature did not exceed 120 F. The findings include:A physical plant inspection was conducted on March 29, 2012 from 1:30 PM to 2:10 PM. At approximately 1:38 PM the temperature for the sink in bedroom #1, measured at 130 F. At approximately 1:57 PM the temperature for the sink in the bathroom on the 3rd floor measured at 130F. The facility director was present during the tour and confirmed the findings.
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Plan of Correction
The Maintenance Coordinator has decreased the water heater temperature gauge to a lower and acceptable setting. The Executive Director has scheduled and appointment with our heating system representatives for May 23, 2012 to investigate ways to secure the system, preventing someone from increasing the temperature of the system beyond regulatory capacity. An appropriate measure will be instituted, if mechanically allowable. If not mechanically allowable, the Maintenance Coordinator will check the water heater temperature gauge weekly to assure compliance. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan that included the clients' goals with timeframes, the reentry process if the client should feel the need to return to service, and/or a contact person for reentry. The findings include:Two client records requiring aftercare plans were reviewed on March 29, 2012. Two out of two client records lacked aftercare plans that documented the client's goals with timeframes, the reentry process if the client should feel the need to return to service, and/or a contact person for reentry, specifically client records #4 and 5.Client # 4 was admitted on April 26, 2011 and discharged on July 30, 2011. The aftercare plan was completed on July 26, 2011 and did not include goals with timeframes.Client # 5 was admitted on September 16, 2011 and discharged on December 9, 2011. The aftercare plan was completed on December 7, 2011 and did not include goals with timeframes, a contact person, or the reentry process in the case that the client would like to return to treatment. The findings were discussed with the facility director prior to the exit interview.
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Plan of Correction
The Clinical Director will amend the current aftercare plan form to include goals, time frames, the re-entry process if a client should feel the need to return to service, and a contact person for the re-entry process. This change will be completed by April 20, 2012. The Clinical Director will review all aftercare plan information form changes and the Clinician's responsibility in completing the form with the client with the Clinical Staff during their scheduled meeting on April 24, 2012. The Clinical Director will then conduct random chart reviews through June 30, 2012 to ensure corrected compliance. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document follow-ups in accordance with the facility's policies and procedures. The findings include:The facility's policy titled "FOLLOW-UP POLICY" states: For All Discharged Clients1. The client's primary therapist or the clinical supervisor will obtain the client's consent to follow-up before the client is discharged from this agency. 2. This follow-up will be performed in all cases where the client has been in treatment for one month or more. 3. the method of contact will be by phone call 90 days after discharge. Two client records requiring follow-ups were reviewed on March 29, 2012. Two out of two client records lacked aftercare plans that documented the client's goals with timeframes, the reentry process if the client should feel the need to return to service, and/or a contact person for reentry, specifically client records #4 and 5.Client # 4 was admitted on April 26, 2011 and discharged on July 30, 2011. A consent to follow-up was documented in the client's record. The follow-up was to be completed by October 30, 2011. As of the date of the inspection, there was no documentation of a follow-up for client #4.Client # 5 was admitted on September 16, 2011 and discharged on December 9, 2011. A consent to follow-up was documented in the client's record. The follow-up was to be completed by March 9, 2011. As of the date of the inspection, there was no documentation of a follow-up for client #5.The findings were discussed with the facility director prior to the exit interview.
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Plan of Correction
The Executive Director will amend the Follow-up Policy to allow for a slightly greater time period in which the follow-up call must be placed. (Presently it reads 90 days after discharge.) This will be completed by April 30, 2012. The Clinical Director will discuss the changes to the follow-up policy and the responsibilities of overall policy compliance with the staff member in charge of this activity. The Clinical Director will then institute a monthly review of the follow-up information policy and procedures to ensure compliance, for a period of three months (May, June, July, 2012). |