INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2021 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of four employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 4.
Employee # 4 was hired as a counselor on January 22, 2020 and was still in this position at the time of the inspection. Based on a review of employee # 4's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning the week of 12/20/21, the Facility Director and Counselor will have a weekly supervision meeting with Counselor, to include oversight of a least one individual session/week and one group oversight/month and documents for a 6 month period. For all new hires, the Project and Facility Director shall review experience and degree to ensure Counselor qualifications are met. If not, the hire will be designated as a Counselor's Assistant and complete required period of supervision. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to keep hot water temperature to not exceed 120 degrees in the staff and client bathrooms. The staff bathroom water temperature was 130 degrees, and the client bathroom water temperature was 140 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Hot water was adjusted by the plant property owner on 12/17/2021 to not exceed water temperature of 120 degrees. Water temperature will be checked on a weekly basis by Facility Director during weekly facility inspection, beginning the week of 12/20/2021. |
709.28 (c) 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.
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Observations
Based on seven of seven client records reviewed, the facility failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record for clients # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on August 13, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 2 was admitted on September 29, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 3 was admitted on August 31, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Also, a correspondence with an "outside facility" dated September 30, 2021 allowed the release of information for the client without an informed and voluntary consent from the client for the disclosure of information.
Client # 4 was admitted on August 17, 2021 and was still active at the time of the inspection. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 5 was admitted on January 27, 2021 and was discharged on March 8, 2021. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 6 was admitted on April 16, 2021 and was discharged on July 7, 2021. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Client # 7 was admitted on February 17, 2021 and was discharged on November 10, 2021. Based on a review of the client's record, there was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. Confirmation from the facility indicated funding was provided for drug and alcohol treatment.
Also, a correspondence with an "outside facility" dated April 23, 2021 allowed the release of information for the client without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project's informed and voluntary consent form will be modified to included disclosure of information of the funding source by the Project Director. Staff will be trained on the modification to the consent and all Clients will have the form presented by 1/8/22, by the Facility Director. The Facility Director will review files to ensure compliance monthly. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.
Client # 5 was admitted on January 27, 2021 and was discharged March 8, 2021. An informed and voluntary consent from the client for the disclosure of information to a probation officer did not have a valid signature by the client prior to the release of information as indicated in a progress note dated March 8, 2021.
Client # 7 was admitted on February 17, 2021 and was discharged on November 10, 2021. An informed and voluntary consent from the client for the disclosure of information dated February 17, 2021 to a probation officer and an emergency contact did not have a valid signature by the client but instead had "OTP-Covid-19" in the signature line.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project's informed and voluntary consent form shall be signed by all Clients beginning on 12/20/21. Staff will be trained ensuring signatures are completed on all consents by the facility director. Additionally, a plan will be put into place to ensure barriers to signature, such as COVID-19, are managed and signed consents are received. The Facility Director will review files to ensure compliance monthly; fully completed by 1/8/2022. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the dated signature of the witness.
Client # 5 was admitted on January 27, 2021 and was discharged March 8, 2021. An informed and voluntary consent from the client for the disclosure of information to a probation officer did not have a valid dated signature by the witness prior to the release of information as indicated in a progress note dated March 8, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A review of client files will be completed after each intake, by the Facility Director, to ensure Intake consent of information is signed appropriately, to include witness of signature. Prior to release of information, a case file will occur, completed by the Counselor and Facility Director to ensure proper release is granted. Training of release of consent procedure shall occur no later than 1/8/2022. |