Friends Hospital Greystone Program, a residential rehabilitation service for adults, was cited by the Pennsylvania Department of Human Services (DHS, formerly known as the Dept. of Public Welfare) during an annual license inspection for deficiencies related to service agreements, written agreement with the County, staff evaluations and medical exams, patient rights, and termination from the program. State regulations require that all Community Residential Rehabilitation Service (CRRS) providers “must participate in the overall system of mental health care as defined in the County Mental Health/Mental Retardation (MH/MR) Plan” and the “CRRS must have a written agreement with the County MH/MR program.” DHS found that the facility did not have the required written agreement with the County MH/MR program and it also did not have a reporting system to the county MH/MR Office in the client’s rights policy. Pennsylvania regulations state that “there must be a written agreement between the CRRS provider and the client.” However, DHS found that one patient at the Greystone Program did not have a dated service agreement to determine whether or not it was negotiated and written during the intake process. Also, DHS found that all of the service agreements with clients “do not break down the specific charges for food, specify goals to be achieved and services to be provided and specify the rights of the client,” as required by state law. DHS also cited the Greystone Program at Friends Hospital for multiple violations related to personnel management, specifically around staff performance evaluations and staff medical exams. DHS found that two staff members had not received a 90 day performance evaluation after being hired per facility policy. DHS also revealed that one staff member had not received an annual performance evaluation as outlined in staff policies. Also, four staff members did not have a physician statement saying that they did not have contagious diseases prior to employment at the facility. DHS also found that the facility’s termination policy did not have explicit discharge criteria for both planned and unplanned termination from the program as required by law. The facility submitted a plan of correction to address the cited deficiencies. The facility contacted the Office of Mental Health Philadelphia almost a month after the inspection and received an outline of a draft agreement with the county that would be finalized during the 4th quarter of 2013.