INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2022, 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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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from April 2021 through February 2022, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 21, 2022, the Executive Director will meet with the staff member overseeing fire drills to review the need to utilize alternative exit strategies to the two exits presently being used, in case one of these paths is blocked. The Executive Director will monitor the Fire Drill Logs of April, May and June of 2022 to verify alternative exits are being utilized. |
709.28 (c) 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.
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Observations
Based on a review of seven client records, the facility failed to keep disclosures of client information within the limits established in the signed informed and voluntary consent from the client in two records reviewed. Client #2 was admitted on September 22, 2021 and discharged on November 8, 2021. The record contained documentation of a letter sent to an attorney on October 19, 2021, which disclosed the nature of the project; however, the client signed consent to release information form did not allow for the disclosure of that information.Client #5 was admitted on December 16, 2021 and was active at the time of the inspection. The record contained documentation of a letter sent to an attorney on March 2, 2022, which disclosed the nature of the project; however, the client signed consent to release information form did not allow for the disclosure of that information.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director, prior to March 22, 2022, will alter the agency's Release of Information form to include the necessary wording regarding the nature of the project. On March 22, 2022, the revised form will be reviewed by the Clinical Director in the Clinical Staff meeting where all staff members involved in documentation will receive instructions on this new format. The Clinical Director will monitor adherence to this requirement during monthly chart reviews and within the supervision process. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection on March 10, 2022, which included an inspection of the drug storage area, the facility failed to include only medications in the refrigerator of the drug storage area. A non-medication item, a urine sample, was also contained in the refrigerator at the time of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to 3/22/2022, the Executive Director will purchase or obtain a separate storage unit for non-medication items. On March 21, 2022, the Executive Director, during an Administrative staff meeting, will instruct all non-clinical staff members of the requirement to store only medications in the now-dedicated medication refrigerator, while storing other items in the new storage unit. On March 22, 2022, the Clinical Director, during a Clinical staff meeting, will instruct all clinical staff members of the requirement to store only medications in the now-dedicated medication refrigerator, while storing other items in the new storage unit. On March 22, 2022, the new storage unit will be placed within the present medication storage area by the Clinical director, at the conclusion of the Clinical staff meeting. During the following months, the Clinical Director will monitor the storage units during daily rounds to verify compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client ' s treatment at the project in one applicable record reviewed.Client #4 was admitted on May 27, 2021 and was therapeutically discharged on July 5, 2021. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the Clinical Staff meeting on March 22, 2022, the Clinical Director will review the requirement for a copy of a client's termination form, and any other client-related material, must be placed in the client's chart. The Clinical Director will monitor adherence to this procedure during monthly chart reviews. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of seven client records, the facility failed to document that the client was given the opportunity to request reconsideration of a decision terminating treatment in one applicable record reviewed.Client #4 was admitted on May 27, 2021 and was therapeutically discharged on July 5, 2021. There was no documentation in the record that the client was given the opportunity to request reconsideration of the decision terminating treatment. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the Clinical Staff meeting on March 22, 2022, the Clinical Director will review the requirement for a copy of a client's termination form to be placed in the client's chart to verify the client was given the opportunity to request reconsideration of a decision terminating treatment. The Clinical Director will monitor adherence to this procedure during the monthly chart reviews. |