INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2023, 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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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in one out of two applicable records reviewed.
Client #2 was admitted on March 8, 2023, and was discharged on April 7, 2023. The treatment plan was dated March 27, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be trained on proper documentation of support systems on Master Treatment Plans on or before 11/1/2023, which is the date of the next scheduled monthly staff meeting.
Facility Director will conduct monthly file audits to ensure compliance post training beginning in October 2023. |