INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2025, 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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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, conducted on January 14, 2025, the facility failed to ensure that all bunkbeds were equipped with a securely attached railing on each open side and open end of the bunk.
The bunkbed in client room number four was not equipped with a securely attached railing on each open side of the bed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and maintenance coordinator will ensure that all bunkbeds are equipped with a securely attached railing on each open side and open end of the bunk.
Senior Associate Manager and maintenance coordinator will do daily checks to ensure each railing is securely in place per regulations. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to verify that work done by the client at the project is an integral part of the treatment and rehabilitation plan in three of seven client records reviewed.
Client #4 was admitted on October 3, 2024 and was discharged on December 27, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on November 10, 2024; however, the treatment plan did not include verification that work done by the client at the project was an integral part of the treatment.
Client #5 was admitted on July 5, 2024 and was discharged on August 26, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on August 2, 2024; however, the treatment plan did not include verification that work done by the client at the project was an integral part of the treatment.
Client #6 was admitted on May 22, 2024 and was discharged on July 12, 2024. A comprehensive treatment and rehabilitation plan was developed with the client on June 22, 2024; however, the treatment plan did not include verification that work done by the client at the project was an integral part of the treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Director will meet for supervision on 1/28/25 and discuss the importance of ensuring each treatment plan includes verification that work done by the client at Good Friends Inc. is an integral part of treatment. Clinical Director will discuss with clinical staff in group supervision 1/28/25 at night.
Clinical Director will ensure the ongoing chance to treatment planning through chart audits each month. |