INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 2017 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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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
A physical plant inspection was conducted on March 28, 2017. The facility failed to provide slip-resistant surfaces in the showers which were located in the second floor main bathroom and in room #8 bathroom. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The two remodeled tile showers will have slip-resistant surfaces installed on the floor surfaces by our maintenance employee before April 7, 2017. This process will be checked, upon notice of their installation, by our Executive Director. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
A physical plant inspection was conducted on March 28, 2017. The facility failed to store frozen food at a temperature of 0F or below. A freezer located in the basement of the facility had a temperature reading of 8F. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On Wednesday, March 29, 2017, our external freezer repairman conducted an on-site inspection of this freezer, noting it was running properly but due to the existence of so much food it was unable to maintain the zero temperature. He recommended the food be stored in a way that allows airflow circulation. Our maintenance employee then redistributed some of this food to other freezers. On Thursday, March 30, 2017 the freezer temperature was zero degrees. Our maintenance employee will monitor all freezers to maintain a zero temperature. |
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
Seven client records were reviewed on March 28, 2017. The facility released patient identifying information to a laboratory and failed to obtain an informed and voluntary consent or a QSOA prior to the disclosure in six client records, specifically #1-6. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Qualified Service Organization Agreement (QSOA) between our agency and its external laboratory provider was obtained and signed by both parties on Tuesday, March 28, 2017. The clinical supervisor will immediately begin to audit charts to ensure that a release of information (and/or a QSOA) has been obtained prior to releasing client information. If needed in lieu of a specific release of information, the facility director will obtain a QSOA for any vendor before client information is sent. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Seven client records were reviewed for client rights on March 28, 2017. The facility failed to include on the facility's Bill of Rights form the following verbiage regarding client rights: age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation and handicap. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On Tuesday, March 28, 2017, the Executive Director altered the agency's Client Bill of Rights form to include the words noted in Observation #0299. On April 4, 2017, the clinical director will meet with all counselors to review the updated form. The clinical supervisor will ensure that the counselors are utilizing the new forms by chart audits, beginning April 4, 2017, by auditing the clinical records and reviewing any issues in either individual or group supervision format. |