D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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B.I. INCORPORATED
125 NORTH WILKES-BARRE BOULEVARD, SUITE 4
WILKES-BARRE, PA 18702

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Survey conducted on 10/31/2024

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on October 31, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, B.I. Incorporated 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.	Plan of Correction
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to: (2) Specific information disclosed.
Observations Based on the review of client records, the facility failed to document a completed consent to release information form, to include specific information to be disclosed, in five out of seven applicable records reviewed. Client #1 was admitted on October 1, 2024, and was still active at the time of the inspection. A consent form dated October 1, 2024, to a county parole facility had "other" selected for information to be disclosed but there was no documentation on the form to specify what additional information was being released. Client #3 was admitted on August 19, 2024, and was still active at the time of the inspection. Two consent forms dated August 19, 2024, to state corrections and an emergency contact, had " other" selected for information to be disclosed but there was no documentation on the form to specify what additional information was being released. Client #4 was admitted on July 25, 2024, and was discharged on October 10, 2024. Two consent forms dated July 25, 2024, to state corrections and an emergency contact, had "other" selected for information to be disclosed but there was no documentation on the form to specify what additional information was being released. Client #5 was admitted on September 13, 2024, and was discharged on October 29, 2024. A consent form dated October 11, 2024, to a county parole office had "other" selected for information to be disclosed but there was no documentation on the form to specify what additional information was being released. Client #6 was admitted on January 9, 2024, and was discharged on May 24, 2024. A consent form dated January 9, 2024, to a state probation office had "other" selected for information to be disclosed but there was no documentation on the form to specify what additional information was being released. This finding was reviewed with facility staff during the licensing inspection.	Plan of Correction The Project and Facility Director shall train counselors by 11/27/24 to include specifically what additional information may be disclosed when reviewing and completing consent to release information form. We will also train on the documentation of this information. Facility Director will review files monthly to ensure compliance. This shall be completed by 11/27/24.