INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6-7, 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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709.91(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 the review of client records, the facility failed to document a complete psychosocial evaluation, to include a clinical summary, in twelve out of twelve applicable records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director shall train counselors to complete psychosocial evaluations to include clinical summaries and retain in clinical records, by 1/5/24. Facility Director shall review two files per month per counselor to ensure compliance, beginning 1/5/24. |
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 a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in seven out of nine applicable client records.
Client #2 was admitted on April 4, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated April 12, 2023, indicated the client would attend one group and one individual session per week. There was no documentation to confirm that the client attended any individual sessions for the period between September 6-September 27, 2023.
Client #3 was admitted on July 28, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated September 11, 2023, indicated the client would attend one group and one individual session per week. There was no documentation to confirm that the client attended any individual sessions for the period between October 5-November 1, 2023.
Client #4 was admitted on September 18, 2023 and was still active at the time of the inspection. The comprehensive treatment plan, dated October 12, 2023, indicated the client would attend one group and one individual session per week. There was no documentation to confirm that the client attended any individual sessions for the period between October 19-October 31, 2023.
Client #5 was admitted on May 4, 2023 and was discharged on August 15, 2023. The comprehensive treatment plan, dated May 30, 2023, indicated the client would attend one group and one individual session per week. There was no documentation to confirm that the client attended any individual sessions for the period between May 4- August 8, 2023. Additionally, there was no documentation to confirm that the client attended any group session for the period between June 13-July 11, 2023.
Client #6 was admitted on February 24, 2023 and was discharged on May 1, 2023. The comprehensive treatment plan, dated March 14, 2023, indicated the client would attend one group and one individual session per week. There was no documentation to confirm that the client attended any individual sessions for the period between March 14-March 29, 2023.
Client #11 was admitted on April 6, 2023 and was discharged on October 19, 2023. The comprehensive treatment plan, dated April 23, 2023, indicated the client would attend one group and one individual session per week. There was no documentation to confirm that the client attended any individual or group sessions for the period between June 13-July 11, 2023.
Client #12 was admitted on June 23, 2023 and was discharged on September 14, 2023. The comprehensive treatment plan, dated July 6, 2023, indicated the client would attend one group and one individual session per week. There was no documentation to confirm that the client attended any individual sessions for the period between August 2-August 9, 2023 and August 11-August 31, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall train counselors to ensure clients are receiving counseling services according to their individual comprehensive treatment plans by 1/5/24. Facility Director shall review two clinical records per counselor to ensure treatment plans and records of services are compliant beginning 1/5/24. |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information in six out of six applicable discharged record reviews.
The facility's policy notes that a follow-up phone call will be completed, and a follow-up form/questionnaire will be sent to discharged clients within 30 days of discharge.
Client #5 was admitted on May 4, 2023, and was discharged on August 15, 2023. There was no documentation that a follow-up form/questionnaire was sent to the client.
Client #6 was admitted on February 24, 2023, and was discharged on May 1, 2023.There was no documentation of a follow-up form/questionnaire in the client's record.
Client #7 was admitted on April 13, 2023, and was discharged on May 4, 2023.There was documentation of a follow-up phone call or form/questionnaire in the client's record.
Client #10 was admitted on April 6, 2023, and was discharged on May 5, 2023.There was no documentation of a follow-up form/questionnaire in the client's record.
Client #11 was admitted on April 6, 2023, and was discharged on October 19, 2023.There was no documentation of a follow-up form/questionnaire in the client's record.
Client #12 was admitted on June 23, 2023, and was discharged on September 14, 2023.There was no documentation of a follow-up form/questionnaire in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall train counselors on follow-up post discharge to include phone call and questionnaire and the documentation of occurrences. Facility Director shall review two discharged clinical records per counselor per month to ensure follow-ups have occurred and are compliant, beginning 1/5/24. |