INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on February 6, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the house manager ' s room on the third floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 10 2023, the Executive Director will meet with staff that had heater in his room and have a formal documented counseling session. The heater will be removed from the facility. No heaters will be permitted inside the facility unless approved by Executive Director that is installed or mounted. This will be monitored on a monthly basis by Clinical Director and Executive Director to ensure this doesn't recur. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from March 2022 through January 2023, the facility failed to conduct fire drills during sleeping hours at least every six months as none of the fire drills were conducted during sleeping hours during the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 10, 2023 Executive Director will meet with staff responsible for conducting monthly fire drills/logs. Fire Drill log will be updated and state that Fire Drills must be conducted every 3 months during sleep times to ensure that facility is following regulations. This will be monitored and addressed in supervision by Executive Director on a monthly basis to ensure this does not recur. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients. The facility failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours in one of one applicable record reviewed.
Client #3 was admitted on July 5, 2022 and discharged Against Facility Advice (AFA) on September 11, 2022. There was no documentation in the client record that the emergency contact was called.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
On February 13, 2023 Executive Director will meet with staff and implement a new document that records the contact of all AFA residents within the 12-hour period. This document will be placed in the resident's chart once completed. Clinical Director will follow up with clinical staff to ensure that the process is being followed moving forward. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Good Friends Inc did obtain the services of a public accountant for fiscal year 21/22, however due to unforeseen circumstances they were not able to complete the audit by the requested time. The fiscal audit for 21/22 will be completed by 2/28/23. For future audit years, Executive Director will request exemption before the end of the calendar year if audit falls behind schedule in future years. In addition, Good Friends Inc will discuss the importance of completing audit with accounting firm within 6 months of the end of fiscal year to ensure it doesn't happen moving forward. In the event that an exception that is not granted ED will have bi-monthly meetings to ensure deadline for audit is not missed. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client records and a review of the facility ' s medication administration policy, the facility failed to follow their policies for control and accountability of drugs in three of four applicable records reviewed.
The facility ' s medication policy states the staff member overseeing client self-administration of medications will record on the accompanying log the time of medication administration or the reason it was not administered.
Client #2 was admitted on September 6, 2022 and discharged on December 2, 2022. The medication log for two medications did not record the time of administration or reason it was not administered on October 24-27, 2022, and October 29, 2022.
Client #6 was admitted on December 2, 2022 and was active at the time of the inspection. The record contained documentation that a medication was ordered for client on January 5, 2023, however, there was no accompanying log to document time of medication administration or reasons for refusal.
Client #7 was admitted on December 30, 2022 and was active at the time of the inspection. The medication log for three medications did not record the time of administration or reason it was not administered on January 30, 2023 and January 31, 2023.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
On February 10 2023, the Executive Director will meet with staff responsible for completing the medication logs. An internal CQI Document will be put in place to monitor the medication logbook on a monthly basis to ensure proper documenting of medication times and to ensure that all medication records are being filed appropriately. This document will be completed by the end of each month. Executive Director will ensure it is being completed through monthly follow up and supervision. |