INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, BI 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During a physical plant inspection and review of the facility fire drill log on February 4, 2020, the facility failed to document the exit route used during the fire drills for the year 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will train Facility Director and assigned personnel on conducting and documenting fire drills by 3/27/20. Project Director will observe fire drill documentation semi-annually to ensure compliance. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the project failed to provide procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to a physical assault or sexual assault by staff or a client. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020 the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to selling or use of illicit drugs on the premises. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the project failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the project failed to develop and implement procedures in responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to theft, burglary, break-in or similar incident at the facility. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to event at the facility requiring the presence of police, fire or ambulance personnel. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to fire or structural damage to the facility. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on documenting, developing and implement a responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the manual did not provide a procedure on documenting unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on documentation of the unusual incident. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the manual did not provide a procedure on the prompt review and identification of the causes directly or indirectly responsible unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on prompt review and identification of the causes directly or indirectly responsible for the unusual incident. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the manual did not provide a procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on implementing a timely and appropriate corrective action plan in response to unusual incidents. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the project ' s policy and procedure manual on February 4, 2020, the manual did not provide a procedure on the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures of ongoing monitoring of the corrective action plan in response to unusual incidents. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on seven of eight client records reviewed on February 4, 2020, the facility failed to document the frequency of individual sessions in the treatment and rehabilitation plan.
Client # 1 was admitted on October 25, 2019 and was still active at the time of the inspection. The treatment and rehabilitation plan developed with the client did not provide the frequency of individual sessions. Also, there was no signature acknowledging the treatment and rehabilitation plan was developed with the client.
Client # 2 was admitted on May 22, 2019 and was discharged on January 30, 2020. A treatment and rehabilitation plan developed with the client did not provide the frequency of individual sessions.
Client # 3 was admitted on July 29, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan developed with the client did not provide the frequency of individual sessions.
Client # 4 was admitted on September 6, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan developed with the client did not provide the frequency of individual sessions.
Client # 5 was admitted on August 19, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan developed with the client did not provide the frequency of individual sessions.
Client # 6 was admitted on September 10, 2019 and was discharged on January 8, 2020. A treatment and rehabilitation plan developed with the client did not provide the frequency of individual sessions.
Client # 8 was admitted on March 22, 2019 and was discharged on October 18, 2020. A treatment and rehabilitation plan developed with the client did not provide the frequency of individual sessions.
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Plan of Correction
POC: Counselors will complete a treatment plan update when the frequency of a participant's Individual Treatment Sessions changes. These treatment plan updates will reflect whether the participant will be scheduled for an individual session: weekly, every other week, or other scheduled occurrance. Facility Director will conduct monthly audits of participant files to ensure compliance. Facility Director will train counselors by 3/13/20. |