INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 25, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and training records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in one of three personnel records reviewed.The findings include:Three personnel records were reviewed on November 25, 2014 for documentation of fire extinguisher training. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 3.Employee #3 was hired at this facility on February 26, 2014. Fire extinguisher training was not provided until October 6, 2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff shall have fire extinguisher training within 7 days of hire. Facility Director will review the file by the 7th day of employment to ensure compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and training records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, in one of three personnel records reviewed.The findings include:Three records requiring documentation that personnel on all shifts were trained to perform assigned tasks during emergencies, were reviewed on November 25, 2014.Employee #3 was hired at this facility on February 26, 2014. The training for assigned tasks during emergencies was documented on October 6, 2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff shall have emergencies training within 7 days of hire. Facility Director will review the file by the 7th day of employment to ensure compliance. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information remained within the limits imposed by 4 Pa. Code 255.5 (b) in one of ten records reviewed.The findings included:Ten client records were reviewed on November 25, 2014. Ten records were reviewed regarding documentation for release of information. The facility failed to ensure that an informed and voluntary consent to release information remained within the limits imposed by 4 Pa. Code 255.5 (b) in client record #1.A consent to release information form with the heading "LCCF" signed and dated by client and staff on April 29, 2014 exceeded the parameters of 4 Pa. Code 255.5 by permitting the release of the following information: summaries of any evaluation; recommendations regarding treatment and supervision plan, service needs, program termination or re-entry; case management reports; and group progress notes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An invalid release of information form was used has now been removed and can no longer mistakenly be used by staff. To ensure it does not occur again, the Facility Director shall review forms regularly to ensure compliance.
Facility Director shall train staff on release of information and 4 Pa. Code 255.5 (b) to achieve compliance. Training shall occur by 1/2/2015.
Facility Director and Lead Counselor will review case files regularly to ensure compliance. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in three of six client records.The findings include:Ten client records were reviewed on November 25, 2014. An aftercare plan was required in six client records. The facility did not document an aftercare plan in client records #3, 5, and 6.Client #3 was admitted on June 10, 2014 and discharged on November 12, 2014. There was no documentation of an aftercare plan in client record #3. Client # 5 was admitted on July 7, 2014 and was discharged on November 3, 2014. There was no documentation of an aftercare plan in client record #5. Client # 6 was admitted on May 20, 2014 and was discharged on November 7, 2014. There was no documentation of an aftercare plan in client record #6. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall train staff on Aftercare Plans to achieve compliance. Training shall occur by 1/2/2015.
Facility Director and Lead Counselor will review case files regularly to ensure compliance of Aftercare Plan in client records.
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