INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25-26, 2013 by staff from the Department of Drug and Alcohol Programs, 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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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 the physical plant inspection, the facility failed ensure that the hot water temperature did not exceed 120Fahrenheit.The findings include:The physical plant inspection took place on March 25, 2013. At approximately 2:00 PM the water temperature was tested in bathroom # 8 and it read 124Fahrenheit. The Project Director confirmed the findings.This is a repeat citation. The facility was previously cited on March 29, 2012 for noncompliance with this standard.
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Plan of Correction
On March 25, 2013 the Maintenance Coordinator decreased the water heater temperature gauge to a lower and acceptable setting upon the discovery of the problem of four degrees. The Reviewer revisited bathroom #8 the following day (March 26, 2013), checked the temperature, and found it in compliance. The Maintenance Coordinator will check the water heater temperature gauge on a weekly basis to assure compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records the facility failed to assure counseling services were provided in accordance with the individual treatment and rehabilitation plan in eight of ten client records reviewed.The findings include:Ten client records were reviewed on March 26, 2013 to ensure that services were being provided in accordance with the individual treatment and rehabilitation plans. The facility failed to provide documentation that services were being provided in accordance with the treatment plans in seven of ten records reviewed, specifically client records # 1, 2, 3, 4, 5, 6, 8, and 9. Client # 1 was admitted into treatment on 11/19/12 and was still an active client at the time of the inspection. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document individual counseling sessions for the following weeks: 12/9/12 and 12/23/12. The facility failed to document group counseling sessions for the following weeks: 12/9/12, 12/30/12, and 2/24/13. Client # 2 was admitted into treatment on 12/5/12 and was still an active client at the time of the inspection. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document individual counseling sessions for the following week: 1/27/13. The facility failed to document group counseling sessions for the following weeks: 12/30/12 and 2/24/13. Client # 3 was admitted into treatment on 12/20/12 and was still an active client at the time of the inspection. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document individual counseling sessions for the following week: 1/27/13. The facility failed to document group counseling sessions for the following weeks: 12/30/12 and 2/24/13Client # 4 was admitted into treatment on 1/7/13 and was still an active client at the time of the inspection. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document individual counseling sessions for the following week: 2/24/13. The facility failed to document group counseling sessions for the following week: 2/24/13. Client # 5 was admitted into treatment on 1/11/13 and was still an active client at the time of the inspection. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document individual counseling sessions for the following week: 2/10/13. The facility failed to document group counseling sessions for the following week: 2/24/13. Client # 6 was admitted into treatment on 1/31/13 and was still an active client at the time of the inspection. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document group counseling sessions for the following week: 2/24/13. Client # 8 was admitted into treatment on 8/20/12 and was discharged on 10/3/12. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document group counseling sessions for the following week: 8/26/12. Client # 9 was admitted into treatment on 8/10/12 and was discharged on 11/10/12. This client was to get one weekly individual counseling session and one weekly group counseling session. The facility failed to document individual counseling sessions for the following week: 10/7/12. The facility failed to document group counseling sessions for the following weeks: 8/26/12 and 10/28/12.The Project Director and the Clinical Director confirmed the findings.
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Plan of Correction
The Clinical Director will meet with the Clinical Staff during their scheduled meeting on April 16, 2013. The Clinical Director will review the specific findings from the Reviewer's survey report. The Clinical Director will review with the staff the need to document each individual and group session, as presently occurring, and reinforce the need to document any session(s) not conducted, along with the reason for the missed session(s). The Clinical Director will review with the staff the records cited and instruct each assigned staff member to add a note to those records specifically explaining why the client did not attend/receive treatment on the specific days referenced in the citation. The Clinical Director will set a completion date for this action as April 30, 2013, at which time the Clinical Director will review each mentioned chart for compliance. The Clinical Director will then conduct random chart reviews through June 30, 2013 to ensure corrected compliance. |