INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16-17, 2009 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 and a plan of correction is due on April 18, 2009.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in three of seven personnel records. Findings:Seven personnel records were reviewed on March 17, 2009. A training plan was required in seven personnel records. The facility did not document a training plan to include the subject areas and the potential resources for the training(s) in personnel records # 3, 4 and 5.
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Plan of Correction
As noted, the training plans did exist but failed to note specific subject areas and resources.
On April 7, 2009, the Executive Director will meet with the Clinical Director who oversees this area to review the specific documentation needs of individual training plans. A second meeting will occur in July. This meeting will review the training plans due at that time to assess alignment and compliance. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document if a copy of the signed consent for the release of information was offered to the client in three of six records.Findings:Six client records were reviewed on March 17, 2009. Documentation of whether the client was offered a copy of the consent to release information was required in six client records. The facility did not document if the client was offered a copy of the release in client records # 2, 4 and 6.Client record # 2, consent forms did not document if the client was offered a copy of release to: Chester County D&A, Community care Behavioral Health, Father and Step-mother, Department of Public Welfare and Delaware County Probation OfficeClient record # 4, consent forms did not document if the client was offered a copy of release to: Montgomery County D&A, Mother, Probation Officer and Department of Public Welfare.Client record # 6, consent form did not document if the client was offered a copy of release to: Department of Public Welfare.
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Plan of Correction
During their supervision meeting on April 8, 2009 the Clinical Director will review with the Intake Coordinator the need to complete each portion of each consent form. The Clinical Director will follow-up this meeting with chart reviews of future consent forms for compliance with this issue. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination in two of four client records.Findings:Six client records were reviewed on March 17, 2009. A physical examination was reviewed in four client records. The facility failed to document a physical examination in client records # 1 and 3.Client record #1, admission date 09/17/08, physical examination not documented at time of inspectionClient record #3, admission date 12/03/08, physical examination not documented at time of inspection
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Plan of Correction
During their supervision meeting on April 8, 2009, the Clinical Director will review with the Intake Coordinator the specific items needed to be included in a physical examination prior to the client being admitted. The Clinical Director will follow-up this meeting with chart reviews of future physical examinations for compliance with this issue. |