INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2025, 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:
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Plan of Correction
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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
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of creed, ethnicity, and marital status in seven or seven records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director shall update policy 709.30 Client Rights by 01/05/26. Facility Director shall train the facility staff on policy and need to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of creed, ethnicity, and marital status by 01/07/2026. Facility Director shall review two files per week to ensure compliance beginning 01/07/2026. Project Director will review policy quarterly. |