INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2013 by staff from the Division of Drug and Alcohol 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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709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based upon the physical plant inspection, the facility failed to post the service fee schedule in a prominent place.
The findings include:
On December 4, 2013 a physical plant tour was conducted. The facility failed to have the service fee schedule posted in a prominent place.
The findings were confirmed by the program director.
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Plan of Correction
Program Manager posted the service fee schedule in the lobby of the facility on 12/06/2013. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of two client records.
The findings include:
Eleven client records were reviewed on December 4, 2013. Two client records were required to have documentation of a notice of involuntary termination. The facility failed to include documentation of the notice to involuntary terminate the client's treatment in client records # 8 and 10.
Client # 8 was involuntarily discharged from treatment on June 6, 2013. There was no documentation of a notice to involuntarily terminate the client's treatment included in the record as of the date of the inspection.
Client #10 was involuntarily discharged from treatment on October 15, 2013. There was no documentation of a notice to involuntarily terminate the client's treatment included in the record as of the date of the inspection.
The program director confirmed the findings.
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Plan of Correction
Lead Therapist obtained documentation from the Facility Director to address Notice of Involuntary Termination.
Lead Therapist received training on how to complete the Notice of Involuntary Termination form and process to notify the client.
The Facility Director is responsible for file audits and reviews. During file audits and reviews, Facility Director will follow up to ensure that this process is being followed. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of two client records.
The findings include:
Eleven client records were reviewed on December 4, 2013. Follow-up information was required to be documented in two client records. The facility failed to document follow-up information in client records # 8 and 10.
Client #8 was discharged from treatment on June 10, 2013. Client follow-up information was due to be documented by July 10, 2013. As of the date of the inspection, there was no follow-up information documented in the client record.
Client #10 was discharged from treatment on October 15, 2013. Client follow-up information was due to be documented by November 15, 2013. As of the date of the inspection, there was no follow-up information documented in the client record.
The findings were not disputed during the exit interview.
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Plan of Correction
Lead Therapist or therapist will follow up with clients 30 days after discharge via phone or in person.
If the client is still incarcerated 30 days after discharge from the drug and alcohol program, Lead Therapist or therapist will document this in the client's file. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on the physical plant inspection, the facility failed to conspicuously display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
The physical plant inspection was conducted on December 4, 2013. The facility failed to conspicuously display an emergency telephone number to the general public.
The program manager confirmed the findings.
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Plan of Correction
Program Manager had a new sign made and installed to post the facility information and emergency telephone number for the general public.
The new sign was installed on 12/20/13 on the front door of the facility. |