INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2021 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 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and four personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #4's personnel record.Employee #4 was hired as a counselor on February 26, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 to December 31, 2020. Employee #4's employee record only documented 10 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will be in compliance with the training clock hours by the end of the 2021 training year. Progression toward the end goal will be monitored by the employee's direct supervisor throughout the 2021 training year. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed as the basement emergency exit contained two maintenance boxes in front of the door. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The two empty cardboard boxes were removed from the noted location. On April 2, 2021, during the inspection's walk-through and with the Inspector present, the Executive Director reviewed with the Maintenance Coordinator the need to have all emergency exits unblocked at all times. The Maintenance Coordinator will continue to monitor adherence to this situation and report any issues to the Executive Director. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all client records were kept locked as the door to the client records room was not latching and the filing cabinets within the room were not locked. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The door in question was discovered in need of repair during the inspection. The door was repaired during the inspection on April 2, 2021 and it was shown to the Inspector, who noted the issue had been corrected. The Maintenance Coordinator will continue to monitor adherence to this situation and report any issues to the Executive Director. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of the facilities medication logbook and medication administration review forms, the facility failed to include time that the medication was given to the client in all seven client records reviewed. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Director will revise the present medication form to include the time a medication(s) was dispensed to the client. The revised form will be reviewed in the Clinical Staff meeting on 4/13/2021 where all staff members involved in documentation on the form will receive instructions on this new process, afterwards the use of the revised form will begin. The Clinical Director will monitor adherence to this requirement during monthly chart reviews and within the supervision process. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of client records and a discussion with facility staff, the facility fails to include medication records in all closed records as the facility stated they shred all medication logs after the client is discharged. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
During the Clinical Staff meeting of 4/13/2021, the Clinical Director will review: the need for a client's medication sheet to be placed in the client's chart upon the client's discharge from the facility; and, the procedure for this to be accomplished. The Clinical Director will monitor adherence to this procedure during the monthly chart reviews. |
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 that all work done by at the project is an integral part of his treatment and rehabilitation plan in all seven client records reviewed. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
During the 4/13/2021 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. |