INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on review of the facility policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures. The policy and procedure manual was not annually updated by signature for the year 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
2022 facility policy review was completed and documented in the DDAP policy binder as of 12/7/22. In order to ensure that this does not happen in the future, a calendar reminder has been placed on the Facility Director's office calendar in 2023 to conduct an annual policy review. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated a preliminary treatment plan be completed at intake.
Client # 1 was admitted on June 29, 2022 and was still active at the time of the inspection. There was no preliminary treatment available in the client record. The first treatment plan documented in the client record occurred on July 26, 2022.
Client # 3 was admitted on June 29, 2022 and was discharged on August 14, 2022. There was no preliminary treatment available in the client record. There was no treatment plan documented in the client record.
Client # 7 was admitted on June 21, 2022 and was discharged on September 21, 2022. There was no preliminary treatment available in the client record. There was no treatment plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will train all personnel on Preliminary Treatment Plan regulation on annual basis. Treatment files will be reviewed monthly to ensure compliance. Preliminary Treatment plan has been added to our intake packet so it becomes part of the intake process, to address noncompliance. |
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 two applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two out of two applicable records.
Client # 1 was admitted on June 29, 2022 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on July 26, 2022. A treatment and rehabilitation plan update was due no later than September 26, 2022 however, there was no treatment plan update documented in the record at the time of the inspection.
Client # 4 was admitted on May 5, 2022 and was discharged on August 15, 2022. A treatment and rehabilitation plan was developed on May 11, 2022. A treatment and rehabilitation plan update was due no later than July 11, 2022 however, there was no documentation of a treatment plan update completed until August 11, 2022 in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the licensing inspection on January 12, 2022.
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Plan of Correction
Facility Director shall train all staff on treatment plan reviews. Treatment plan review alerts will be placed on office calendar to ensure they are done in a more timely manner. Facility Director will review files monthly to ensure compliance on 60-day file review. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of seven client records, the facility failed to document and complete follow up information in four of four applicable client records.
Client #3 was admitted on June 29, 2022 and was discharged on August 14, 2022. There was no documentation of follow up information being completed in the client record.
Client #4 was admitted on May 5, 2022 and was discharged on August 17, 2022. There was no documentation of follow up information being completed in the client record.
Client #6 was admitted on August 31, 2022 and was discharged on October 5, 2022. There was no documentation of follow up information being completed in the client record.
Client #7 was admitted on June 21, 2022 and was discharged on September 21, 2022. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall train staff on follow up regulation. Follow up forms will be developed and prepared with client name, date of discharge, and phone number at the client's final appointment. Follow up will be placed on office calendar for 30, 60, and 90 days post discharge for all participants unless deceased or incarcerated. Facility Director shall review discharge files monthly for compliance. |