INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 24, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, B. I. Incorporated Inc. 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)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to disclose to the client the criteria for admission, treatment, completion and discharge in six of six client records.
The findings include:
Six client records were reviewed on November 24, 2014. All six records did not include documentation of the criteria for admission, treatment, completion and discharge.
Client #1 was admitted to treatment on October 1, 2014. Intake procedures did not include documentation of client of criteria for admission, treatment, completion and discharge.
Client #2 was admitted to treatment on July 31, 2014 and was discharged on September 24, 2014. Intake procedures did not include documentation of client of criteria for admission, treatment, completion and discharge.
Client #3 was admitted to treatment on March 5, 2014 and was discharged on August 28, 2014. Intake procedures did not include documentation of client of criteria for admission, treatment, completion and discharge.
Client #4 was admitted to treatment on August 22, 2014. Intake procedures did not include documentation of client of criteria for admission, treatment, completion and discharge.
Client #5 was admitted to treatment on August 27, 2014. Intake procedures did not include documentation of client of criteria for admission, treatment, completion and discharge.
Client #6 was admitted to treatment on September 30, 2014. Intake procedures did not include documentation of client of criteria for admission, treatment, completion and discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Criteria for admission, treatment, completion, and discharge will be disclosed and reviewed with the client during the drug and alcohol intake process. The counselor and client will sign the document after review. The document will be placed in the client's chart.
- The counselors obtained documentation from the Facility Director to address intake and admission criteria.
- The counselors received training on how to provide the intake and admission information to the client during the intake process.
- The Facility Director is responsible for file audits and reviews. During file audits and reviews, Facility Director will follow up to ensure that this process is being followed. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to disclose to the client the project policies, hours of operation, fee schedule, and services provided in six of six client records.
The findings include:
Six client records were reviewed on November 24, 2014. All six records did not include disclosure to the client the project policies, hours of operation, fee schedule, and services provided.
Client #1 was admitted to treatment on October 1, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided.
Client #2 was admitted to treatment on July 31, 2014 and was discharged on September 24, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided.
Client #3 was admitted to treatment on March 5, 2014 and was discharged on August 28, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided.
Client #4 was admitted to treatment on August 22, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided.
Client #5 was admitted to treatment on August 27, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided.
Client #6 was admitted to treatment on September 30, 2014. There was no documentation of disclosure to the client regarding the project policies, hours of operation, fee schedule, and services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Drug and Alcohol Orientation Checklist will be implemented during the drug and alcohol intake process. The counselor will review the checklist outlining criteria for admission, client rights, treatment, modality, involuntary discharge/termination criteria, project policies, attendance, check-ins, Drug and Alcohol policies, and community and facility safety. The counselor and client will sign the document after review. The document will be placed in the client's chart.
The counselors obtained documentation from the Facility Director to address client orientation.
The counselors received training on how to implement the client orientation checklist during the intake process.
The Facility Director is responsible for file audits and reviews. During file audits and reviews, Facility Director will follow up to ensure that this process is being followed. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in six of six client records.
The findings include:
Six client records were reviewed on November 24, 2014. Six client records included an individual treatment and rehabilitation plan. The facility failed to document the type and frequency of treatment and rehabilitation services in all six client records.
Client #1 was admitted to treatment on October 1, 2014. An individual treatment and rehabilitation plan was completed on 10-1-2104, but did not include the type or frequency of treatment and rehabilitation services for individual sessions.
Client #2 was admitted to treatment on July 31, 2014 and was discharged on September 24, 2014. An individual treatment and rehabilitation plan was completed on 8-2-2104, but did not include the type or frequency of treatment and rehabilitation services for individual sessions.
Client #3 was admitted to treatment on March 5, 2014 and was discharged on August 28, 2014. An individual treatment and rehabilitation plan was completed on 4-8-2104, but did not include the type or frequency of treatment and rehabilitation services for individual sessions.
Client #4 was admitted to treatment on August 22, 2014. An individual treatment and rehabilitation plan was completed on 9-22-2104, but did not include the type or frequency of treatment and rehabilitation services for individual sessions.
Client #5 was admitted to treatment on August 27, 2014. An individual treatment and rehabilitation plan was completed on 9-17-2104, but did not include the type or frequency of treatment and rehabilitation services for individual sessions.
Client #6 was admitted to treatment on September 30, 2014. An individual treatment and rehabilitation plan was completed on 10-20-2104, but did not include the type or frequency of treatment and rehabilitation services for individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The type and frequency will be noted on page four of the individual treatment and rehabilitation plan form.
- The Facility Director reviewed the Treatment and Rehabilitation Services plan with the counselors to address the frequency and type of treatment.
- The Facility Director is responsible for file audits and reviews. During file audits and reviews, Facility Director will follow up to ensure that this process is being followed. |