INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, B.I. Incorporated (Wilkes-Barre) 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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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of client records, the facility failed to comply with 4 Pa. Code 255.5 and 42 CFR 2.32 regarding the prohibition of redisclosure on the Consent to Release Information Forms in nine of nine client records.
The findings included:
Nine client records were reviewed on December 3, 2013. All nine client records required an informed and voluntary consent to release information form from the client. The facility failed to include on their Consent Forms the following notice to accompany the disclosure prohibiting the redisclosure of information: "This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient." in client record #s 1, 2, 3, 4, 5, 6, 7, 8, and 9.
The Project Director confirmed the findings.
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Plan of Correction
The project director has replaced the redisclosure statment with the following statement to be used as of 12/16/13: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
The facility director shall be responsible for performing monthly file reviews to ensure the form including the amended statement is in use. The facility director will also traing existing staff and train new staff on Consent to Release Information Form. The training shall be completed by 12/23/13. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection, the non-residential facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on December 3, 2013. During the inspection, two areas of the carpet inside the facility were observed to be ripping/tearing apart thus creating a tripping hazard for clients, staff, and visitors. Both of the ripped/torn areas were located in the common area/hallway. The first tear was directly in front of one of the group rooms and the second tear was located in front of one of the offices.
The Project Director confirmed the findings.
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Plan of Correction
The project director has made arrangements with the building landlord to repair carpeting by 1/31/2014.
The facility director shall be responsible for overseeing weekly facility inspections, to include safety and hazardous plant environment. The facility director shall report to project director any risk and plan to immediately address potential hazardous plant environment. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an overheard counseling session during the facility licensure inspection, the facility failed to ensure privacy in order that counseling sessions could not be seen or heard outside the counseling room.
The findings include:
On December 3, 2013 at approximately 11:30 AM, a counseling session between a counselor and a client was overheard by the licensing specialists. The licensing specialists were located in a conference room adjacent to to the office where the counseling session was taking place. There is a white noise machine located inside the counselor's office, however, the licensing specialists were unable to determine if the white noise machine was being utilized at the time of the session.
The Project Director and the Lead Counselor confirmed the findings.
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Plan of Correction
The project director will be responsible for overseeing use of white noise machines located in common hallway, pursuant to the recommendation of licensing specialists.
The location of white noise machines shall include outside counselor offices, while individual sessions are occuring and outside groups rooms, while sessions are occuring.
The facility director shall observe compliance as part of weekly facility safety inspections. The facility director shall also train existing and new staff on proper use and placement of white noise machines. |
709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on the review of client records, the facility failed to assure that there was a complete client record on an individual which includes information relative to the client's involvement with the project. The facility's medication records indicated the name of the medication and the dosage, however failed to document the frequency of use in nine of nine records.
The findings include:
Nine client records requiring documentation of the name of the medication, the dosage, and the frequency of use were reviewed were reviewed on December 3, 2013. The facility failed to document the frequency of the drug in the medication records in client record #s 1, 2, 3, 4, 5, 6, 7, 8, and 9.
The Project Director confirmed the findings.
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Plan of Correction
The project director has overseen the addition of frequency of use to the client records. The project director has properly trained staff of documenting frquency of use with client records.
The facility director shall be responsible for performing monthly file reviews to ensure the form including the amended frequency of use is in use. The facility director will also traing existing staff and train new staff on documenting frequency of use of medications. The training shall be completed by 12/23/13. |