INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 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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709.28 (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 must 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 document a completed consent to release information form in one out of seven records reviewed, as the form was missing required information.
Client #2 was admitted on November 18, 2022 and was still active at the time of the inspection. A consent to release form to a health care agency dated December 28, 2022, listed had "other" box checked without listed what other information could be released.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During case consults, counselors will peer review new charts to ensure all paperwork is accurate. Counselors will note on the case consult form the results of the peer review. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in two out of seven records reviewed, as the forms were missing whether a copy had been offered to the client.
Client #4 was admitted on June 14, 2022 and discharged on November 21, 2022. The consent form was dated June 14, 2022 to probation.
Client #7 was admitted on September 14, 2022 and discharged on December 28, 2022. The consent form was dated September 14, 2022 to probation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During case consults, counselors will peer review new charts to ensure all paperwork is accurate. Counselors will note on the case consult form the results of the peer review. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates with the regulatory timeframe in two out of five applicable records.
Client #3 was admitted on April 13, 2022 and discharged on August 12, 2022. A treatment plan was completed on April 13, 2022 and the next update was due no later than May 13, 2022; however, the next update was completed on July 8, 2022.
Client #4 was admitted on June 14, 2022 and discharged on November 21, 2022. A treatment plan was completed on July 5, 2022 and the next update was due no later than August 5, 2022; however, there were no updates completed at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan reviews will be tracked by counselors using a spreadsheet. A hard copy of the spreadsheet will be placed into the chart to ensure the reviews are completed within the designated timeframe. |