INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2022 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) 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 six of six 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, and 6.
Client # 1 was admitted on November 1, 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 November 19, 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 until January 6, 2022. Confirmation from the facility indicated funding was provided for drug and alcohol treatment on November 19, December 3, 10, 17, 23, and 31, 2021.
Client # 3 was admitted on October 27, 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 # 4 was admitted on November 16, 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 until January 11, 2022. Confirmation from the facility indicated funding was provided for drug and alcohol treatment on November 16, 29, December 6, 13, 20, 21, 2021, and January 3, 2022.
Client # 5 was admitted on December 8, 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 until January 6, 2022. Confirmation from the facility indicated funding was provided for drug and alcohol treatment on December 8, 9, 16, 23, and 30, 2021.
Client # 6 was admitted on October 6, 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 until January 11, 2022. Confirmation from the facility indicated funding was provided for drug and alcohol treatment on October 6, 18, 25, November 1, 8, 15, 22, 29, December 6, 14, 20, 31, 2021 and January 3, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/12/2022, the funding source release of information was added to the AOD intake packet. This means the billing ROI will be completed prior to the ASAM being completed. Billing is not invoiced until the month end and after all ASAM evaluations are completed. Facility Director is responsible for ensuring billing/invoicing ROI is in the file prior to invoice being sent. |
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 one of six client records reviewed, the facility failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client to include acknowledgement that a copy of the client consent was offered to the client in client record # 1.
Client # 1 was admitted on November 1, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to probation/parole did not provide acknowledgement of a copy being offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/12/2022, Facility Director will review releases of information for accuracy and completion prior to the client leaving the facility. Incomplete releases of information will be given back to the client, reviewed for understanding, and completed by client. Facility Director is the one responsible for releasing information and will ensure the ROI is complete and in the file prior to information being released. |
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 two of five applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and update at least every sixty days in client records # 3 and 6.
Client # 3 was admitted on October 27, 2021 and was still active at the time of the inspection. A treatment plan was developed on November 3, 2021. A treatment plan update was due no later than January 3, 2022. There was no treatment plan update in the client record.
Client # 6 was admitted on October 6, 2021 and was still active at the time of the inspection. A treatment plan was developed on October 25, 2021. A treatment plan update was due no later than December 25, 2021. There was no treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will incorporate AOD files into the monthly QA to ensure treatment plans are being completed within the required timeframe.
Facility Director is the individual providing all Drug and Alcohol services at this time. Facility Director will ensure the treatment plan, case notes, and service sign off match on a weekly basis. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on three of five applicable client records reviewed, the facility failed to provide documentation assuring counseling services are provided according to the individual treatment and rehabilitation plan in client records # 2, 4, and 6.
Client # 2 was admitted on November 19, 2021 and was still active at the time of the inspection. The comprehensive treatment plan developed on December 3, 2021 indicated one individual and 1 group per week. The record of service indicates all sessions were group sessions. Although the progress notes indicate individual sessions, confirmation with the facility acknowledges these were all group sessions.
Client # 4 was admitted on November 16, 2021 and was still active at the time of the inspection. The comprehensive treatment plan developed on December 6, 2021 indicated one individual and 1 group per week. The record of service indicates all sessions were group sessions. Although the progress notes indicate individual sessions, confirmation with the facility acknowledges these were all group sessions.
Client # 6 was admitted on October 6, 2021 and was still active at the time of the inspection. The comprehensive treatment plan developed on October 25, 2021 indicated one individual and 0 group per week. The record of service indicates all sessions were group sessions. Although the progress notes indicate individual sessions, confirmation with the facility acknowledges these were all group sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will incorporate AOD files into the monthly QA process to ensure accurate records/notes are being completed and match the treatment plan.
Facility Director is the person providing all AOD services. Facility Director will identify group and individual sessions per week on the treatment plan based on the ASAM level of care recommendation. All missed appointments will be documented via case note in file. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record to include accurate documentation of progress notes.
Client # 2 was admitted on November 19, 2021 and was still active at the time of the inspection. The record of service indicates December 3, 10, 17, 23, and 31 to be group sessions. Progress notes on those dates indicate, individual sessions, confirmation with the facility acknowledges these were all group sessions.
Client # 3 was admitted on October 27, 2021 and was still active at the time of the inspection. The record of service indicates November 5, 11, 19, and December 14 to be group sessions. Progress notes on those dates indicate, individual sessions, confirmation with the facility acknowledges these were all group sessions.
Client # 4 was admitted on November 16, 2021 and was still active at the time of the inspection. The record of service indicates December 6, 13, 20, 27 to be group sessions. Progress notes on those dates indicate, individual sessions, confirmation with the facility acknowledges these were all group sessions.
Client # 5 was admitted on December 8, 2021 and was still active at the time of the inspection. The record of service indicates December 23 and 30 to be group sessions. Progress notes on those dates indicate, individual sessions, confirmation with the facility acknowledges these were all group sessions.
Client # 6 was admitted on October 6, 2021 and was still active at the time of the inspection. The record of service indicates November 1, 8, 15, 22, December 6, 14, 20, and 31 to be group sessions. Progress notes on those dates indicate, individual sessions, confirmation with the facility acknowledges these were all group sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff member responsible for these notes resigned in January 2022, therefore this will no longer be an issue. To ensure this, Facility Director will review AOD files on a monthly basis to ensure the notes match the service provided. |