INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 2021 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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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on review of seven client records on February 26, 2021, the project failed to include documentation of the clients being notified that the project may not discriminate in the provision of services based on creed, ethnicity, marital status, and handicap.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project updated the written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights to include the project may not discriminate in the provision of services based on creed, ethnicity, marital status, and handicap. |
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 four out of seven client records, the facility failed to review and update treatment and rehabilitation plans every 60 days.
Client #1 was admitted on September 20, 2020 and was current at the time of the inspection. Client #1 had a treatment plan on September 29, 2020 with no further treatment plans documented in the client record.
Client #2 was admitted on September 8, 2020 and was current at the time of the inspection. Client # 2 had a treatment plan on September 8, 2020 and the next was not documented until
December 4, 2020.
Client #4 was admitted on August 31, 2020 and was current at the time of the inspection. Client #4 had a treatment plan on September 1 2020 and the next was documented on November 12, 2020. There were no further treatment plans documented in the client record.
Client #5 was admitted on April 24, 2019 and was discharged on August 22, 2019.
Client #5 had a treatment plan on May 8, 2019 with no further treatment plans documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project updated the formulas within the tracking spreadsheet to ensure all treatment and rehabilitation plans are reviewed and updated at least every 60 days. |