INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, BI 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a physical plant inspection and review of fire drill logs on February 13, 2020, the facility failed to document the exit used during the fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC: Project Director will train Facility Director and assigned personnel on conducting and documenting fire drills by 3/27/20. Project Director will observe fire drill documentation semi-annually to ensure compliance. |
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 five of eight client records reviewed, the project failed to obtain a complete informed and voluntary consent to disclose form to include the information to be released.
Client # 2 was admitted on August 1, 2019 and was still an active client at the time of the inspection. An informed and voluntary consent to disclose form to a probation officer dated August 1, 2019 did not provide the information to be disclosed.
Client # 5 was admitted on February 14, 2019 and was discharged July 24, 2019. An informed and voluntary consent to disclose form to a probation officer dated February 14, 2019 did not provide the information to be disclosed.
Client # 6 was admitted on May 30, 2019 and was discharged September 19, 2019. An informed and voluntary consent to disclose form to a probation officer dated May 30, 2019 did not provide the information to be disclosed.
Client # 7 was admitted on June 12, 2019 and was discharged September 26, 2019. An informed and voluntary consent to disclose form to a probation officer dated June 12, 2019 did not provide the information to be disclosed.
Client # 8 was admitted on March 26, 2019 and was discharged July 11, 2019. An informed and voluntary consent to disclose form to a probation officer dated March 26, 2019 did not provide the information to be disclosed.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project and/or Facility Director will train counselors on obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent will be obtained in writing and maintained in the client record and include, but not be limited to: Specific information disclosed. This will occur by 3/13/20. Facility Director will conduct monthly chart audits to ensure compliance. Facility Director and counselors will review and update active clients records to address changes to voluntary consent. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project failed to provide procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to a physical assault or sexual assault by staff or a client. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020 the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to selling or use of illicit drugs on the premises. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project failed to develop and implement procedures in responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to theft, burglary, break-in or similar incident at the facility. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to event at the facility requiring the presence of police, fire or ambulance personnel. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to fire or structural damage to the facility. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on documenting, developing and implement a responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project's policy and procedure manual did not provide a procedure on documenting unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on documentation of the unusual incident. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project's policy and procedure manual did not provide a procedure on the prompt review and identification of the causes directly or indirectly responsible unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on prompt review and identification of the causes directly or indirectly responsible for the unusual incident. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project ' s policy and procedure manual did not provide a procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on implementing a timely and appropriate corrective action plan in response to unusual incidents. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project ' s policy and procedure manual did not provide a procedure on the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures of ongoing monitoring of the corrective action plan in response to unusual incidents. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the project ' s policy and procedure manual on February 13, 2020, the project ' s policy and procedure manual did not provide a procedure on a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
POC: Project policy and procedure manual was amended to include procedures on reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on four of eight client records reviewed on February 13, 2020, the facility failed to provide documentation of a psychosocial evaluation.
Client # 1 was admitted on September 20, 2019 and was still active at the time of the inspection. There was not a psychosocial evaluation provided in the client record.
Client # 3 was admitted on October 24, 2019 and was still active at the time of the inspection. There was not a psychosocial evaluation provided in the client record.
Client # 4 was admitted on December 13, 2019 and was still active at the time of the inspection. There was not a psychosocial evaluation provided in the client record.
Client # 5 was admitted on September 20, 2019 and was discharged July 24, 2019. There was not a psychosocial evaluation provided in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The psychosocial evaluation form will include an additional section for the counselor to document his/her overall evaluation of the information and an assessment of treatment based on the evaluation. Facility Director will conduct monthly audits of participant files to ensure compliance. Facility Director will train counselors by 3/13/20. |
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 of eight client records reviewed on February 13, 2020, the facility failed to complete treatment and rehabilitation plan updates in the regulatory timeframe.
Client # 2 was admitted on August 1, 2019 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on August 21, 2019. A treatment and rehabilitation plan update was due on October 21, 2019. The next update did not occur until February 6, 2020.
Client # 3 was admitted on October 24, 2019 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on October 31, 2019. A treatment and rehabilitation plan update was due on December 31, 2019. The next update did not occur until January 15, 2020.
Client # 5 was admitted on February 14, 2019 and was discharged on July 24, 2019. A comprehensive treatment and rehabilitation plan was developed with the client on March 5, 2019. A treatment and rehabilitation plan update was due on May 5, 2019. There were no updates in the client record.
Client # 8 was admitted on March 26, 2019 and was discharged on July 11, 2019. A comprehensive treatment and rehabilitation plan was developed with the client on April 3, 2019. A treatment and rehabilitation plan update was due on June 3, 2019. There were no updates 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 review the treatment plans with counselors to include updates on the frequency of individual sessions when completing the treatment plan updates by 3/13/20. Facility Director will conduct monthly chart audits to ensure compliance. |
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 four of eight client records reviewed on February 13, 2020, the facility failed to document services being provided according to the individual treatment and rehabilitation plan.
Client # 1 was admitted on September 20, 2019 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed with the client on October 9, 2019 indicated two individual sessions per month. The client record of service and progress notes documented individual sessions to have occurred only on October 9, 2019, November 6, 2019, and December 4, 2019.
Client # 2 was admitted on August 1, 2019 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed with the client on August 21, 2019 indicated one individual session per week. The client record of service and progress notes documented individual sessions to have only occurred on November 13, 2019, and December 2 and 6, 2019.
Client # 3 was admitted on October 24, 2019 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed with the client on October 31, 2019 indicated one individual session per week. The client record of service and progress notes documented individual sessions to have only occurred on December 5 and 19, 2019, and January 2 and 28, 2020.
Client # 5 was admitted on February 14, 2019 and was discharged on July 24, 2019. The comprehensive treatment and rehabilitation plan developed with the client on March 5, 2019 indicated one individual session per week. The client record of service and progress notes documented individual sessions to have only occurred on June 10, 2019, April 17, 2019 and February 14, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will document when a client does not attend a scheduled event or individual session. Facility Director will conduct monthly chart audits to ensure compliance. Facility Director will train counselors by 3/13/20. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on three of eight client records reviewed on February 13, 2020, the facility failed to provide case consultations in accordance with the project ' s policy and procedure manual. Case consultations are to occur every three months for the first year of service.
Client # 2 was admitted on August 1, 2019 and was still active at the time of the inspection. A case consultation was due on November 19, 2019. There was no documentation in the client record the case consultation occurred.
Client # 5 was admitted on February 14, 2019 and was discharged on July 24, 2019. A case consultation was due on May 14, 2019. There was no documentation in the client record the case consultation occurred.
Client # 5 was admitted on March 26, 2019 and was discharged on July 11, 2019. A case consultation was due on June 26, 2019. There was no documentation in the client record the case consultation occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and counselors will create a check list to ensure the case consults are completed within the specific time frame. Facility Director will conduct monthly chart audits to ensure compliance. Facility Director will train counselors by 3/13/20. |