INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2015 and February 19, 2015 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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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.The findings include: A physical plant inspection was conducted on February 19, 2015, at approximately 12:30PM.The facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The facility has one fire extinguisher that was expired and last inspected September 2013.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has contacted our fire extinguisher company to schedule the inspection and update of this extinguisher, to be conducted on March 10, 2015. The Executive Director has created a fire extinguisher location form to be utilized by the external fire extinguisher company when they inspect the premises. The form includes the location of all devices, a checklist for inclusion in the inspection, and the signature of the inspector. This sheet will be reviewed by the maintenance staff member at Good Friends, Inc. post-inspection to verify each fire extinguisher has been inspected and approved, then filed in the Fire Safety Log Book. This form has been created and has immediately become effective. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in five of eleven client records reviewed.The findings include:Eleven client records were reviewed for documentation of a complete client record on February 18, 2015 and February 19, 2015. The facility failed to document a complete record in client records #2, 4, 5, 7, and 9. Client #2 was admitted on 12/10/14 and was still active at the time of the licensing inspection. A progress note indicated the client had an individual session on 1/27/15. The record of service for the client did not indicate an individual session on 1/27/15. The record of service for the client indicated an individual session on 1/28/15. A progress note for an individual session on 1/28/15 was not found in the client's record. A progress note indicated the client had an individual session on 1/14/15. The record of service for the client did not indicate an individual session on 1/14/15. A progress note indicated the client had an individual session on 1/6/15. The record of service for the client had a marking on the line between the dates 1/6/15 and 1/7/15, to indicate an individual session. It was not clear whether the individual session occurred on 1/6/15 or 1/7/15. Client #4 was admitted on 1/9/15 and was still active at the time of the licensing inspection. A progress note indicated the client had an individual session on 1/28/15. The record of service for the client did not indicate an individual session on 1/28/15. A progress note indicated the client had an individual session on 1/14/15. The record of service for the client did not indicate an individual session on 1/14/15. Client #5 was admitted on 1/20/15 and was still active at the time of the licensing inspection. A progress note indicated the client had an individual session on 2/4/15. The record of service for the client did not indicate an individual session on 2/4/15. The record of service for the client indicated an individual session on 2/5/15. A progress note for an individual session on 2/5/15 was not found in the client's record. A progress note indicated the client had an individual session on 1/29/15. The record of service for the client did not indicate an individual session on 1/29/15. The record of service for the client indicated an individual session on 1/30/15. A progress note indicating an individual session on 1/30/15 was not found in the client's record. Client #7 was admitted on 1/29/15 and was still active at the time of the licensing inspection. A progress note indicated client had an individual session on 2/11/15. The record of service for the client did not indicate an individual session on 2/11/15. The record of service for the client indicated the client attended group sessions on 2/3/15 and 2/10/15. Progress notes for groups sessions on 2/3/15 and 2/10/15 were not found in the client's record. A progress note indicated the client attended a life skills group session on 2/11/15. The record of service for the client did not indicate the client attended a life skills group session on 2/11/15. Client #9 was admitted on 4/14/14 and discharged on 6/3/14. A progress note indicated the client had an individual session on 4/17/14. The record of service for the client did not indicate an individual session on 4/17/14. The record of service indicated client had an individual session on 4/18/14. A progress note for an individual session on 4/18/14 was not found in the client's record. A progress note dated 4/24/14 indicated the client missed two sessions during that week. The record of service for the client did not indicate any missed sessions for the week of 4/24/14. A progress note indicated the client had an individual session on 5/20/14. The record of service for the client did not indicate an individual session on 5/20/14. The record of service for the client indicated an individual session on 5/22/14. A progress note for an individual session on 5/22/14 was not found in the client's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 17, 2015, the Clinical Director will review with all clinical staff members the specifics of this deficiency. The Clinical Director will discuss the need to be more cautious when completing the record of service form to be consistent with the recorded documentation from various types of sessions/encounters. The Clinical Director will review the need to record any missed appointments in the client record of service as well as the timely filing of any clinical notes/material. The Clinical Director will monitor compliance through monthly record reviews. |