INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 2024, 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) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of fire drill logs from February 2023 through December 2023, the facility failed to conduct fire drills on different staffing shifts as each of the fire drills were conducted between 10:00 p.m. and 12:10 a.m.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 1, 2024 the 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 on different times of the day and night and on different staffing shifts that facility is following regulations. This will be monitored and addressed in supervision by Executive Director monthly to ensure this does not recur. |
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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 6 was admitted on December 7, 2023 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a government agency on February 1, 2024, however, the record did not contain a client signed consent to release information form to the agency.
Client # 7 was admitted on November 22, 2023 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a government agency on February 1, 2024, however, the record did not contain a client signed consent to release information form to the agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director, prior to March 1, 2024, will add a Release of Information form to include a ROI for Department of Human Services. On March 1, 2024, 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 ensuring the new ROI is included and signed off on by each new client upon entrance into the program. Active clients will be given the opportunity to sign the ROI form beginning March 1, 2024. The Clinical Director will monitor adherence to this requirement during monthly chart reviews and within the supervision process. |
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 eight 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 of two applicable records reviewed.
Client # 5 was admitted on December 14, 2023 and was administratively discharged on January 11, 2024. 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 5, 2024, 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. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan signed by the client, in one of two applicable records reviewed.
Client # 1 was admitted on July 31, 2023 and was discharged on October 30, 2023. The aftercare plan presented by facility staff was not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the Clinical Staff meeting on March 5, 2024, the Clinical Director will review the policy for aftercare planning with the clinical staff. The importance of capturing signatures and ensuring the client's involvement in the aftercare process. The Clinical Director will monitor adherence to this procedure during monthly chart reviews. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information within three months of discharge, per facility policy, in two of three applicable records reviewed.
Client # 2 was admitted on June 27, 2023 and was discharged on September 4, 2023. The follow-up information was due to be completed by December 4, 2023; however, follow-up information was not documented until December 28, 2023.
Client # 3 was admitted on April 4, 2023 and was discharged on June 17, 2023. The follow-up information was due to be completed by September 17, 2023; however, follow-up information was not documented until September 28, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/4/24, the policy on Follow-up for Good Friends Inc. will be modified to include information relative to the client's involvement with the project to include follow-up information within 4 months (120 days) of discharge. The modified policy will be discussed with staff at the clinical meeting on March 5, 2024. Executive Director will monitor monthly to ensure follow-up contacts are being made by our policy. |
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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in two of six applicable client records reviewed.
Client # 1 was admitted on July 31, 2023 and was discharged on October 30, 2023.
Client # 6 was admitted on December 7, 2023 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the 3/12/2024 Clinical Staff meeting, the Clinical Director will conduct an in-service training to educate staff on treatment planning as it relates to work therapy. The review will include examples of previous documentation that was thought to be aligned to this standard and acceptable documentation. The Clinical Director will monitor adherence to this standard during monthly chart reviews and within the supervision process. |