INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2024, 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. A water temperature reading was taken at the bathroom closest to the computer lab, the hot water was recorded at 139 This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall contact building maintenance to adjust water temp to not exceeding 120*. Facility Director shall recheck temperatures during weekly facility inspections. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of client in one out of seven applicable records reviewed.
Client # 2 was admitted on May 8, 2024, and was still active at that the time of the inspection. A release of information dated May 8, 2024. to a payor, documented a client signature; however, it did not document a date.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director shall retrain staff on fully completing the voluntary consent, including dating the document. The training shall occur by 1/7/2025. The Facility Director shall observe dates on voluntary consent in file reviews conducted on a bi-weekly basis. |
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 a review of client records, the facility failed to document a complete psychosocial evaluation in four of seven applicable client records.
Client #4 was admitted on June 14, 2024, and discharged on July 31, 2024. A psychosocial evaluation was completed on June 14, 2024; however, the clinical summary was incomplete.
Client #5 was admitted on March 21, 2024, and discharged on May 25, 2024. A psychosocial evaluation was completed on March 21, 2024; however, the clinical summary was incomplete.
Client #6 was admitted on August 14, 2024, and discharged on November 14, 2024. A psychosocial evaluation was completed on August 14, 2024; however, the clinical summary was incomplete.
Client #7 was admitted on August 20, 2024, and discharged on November 6, 2024. A psychosocial evaluation was completed on August 21, 2024; however, the clinical summary was incomplete.
This is a repeat ciation from the Novmeber 7, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director shall train staff on the completion of the psychosocial evaluation within the required timeframe. This shall occur by 01/07/25. Facility Director shall reviews records bi-weekly to ensure psychosocial evaluations are completed within the requirements and retrain if necessary. Facility Director shall review all active files to ensure these have completed psychosocial evaluations by 1/7/25. |
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 client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of seven applicable records reviewed.
Client #2 was admitted on May 8, 2024, and was still active at the time of the inspection. The treatment plan dated June 4, 2024, indicated one group therapy session per week and one individual session per week. There was no documentation of the client receiving individual therapy between October 6-26, 2024.
Client #3 was admitted on September 18, 2024, and was still active at the time of the inspection. The treatment plan dated September 26, 2024, indicated one group therapy session per week and one individual session per week. There was no documentation of the client receiving individual therapy between November 3-30, 2024.
Client #4 was admitted on June 14, 2024, and discharged on July 31, 2024. The treatment plan dated July 10, 2024, indicated one group therapy session per week and one individual session per week. There was no documentation of the client receiving individual therapy between July 14-27, 2024.
Client #5 was admitted on March 21, 2024, and discharged on May 25, 2024. The treatment plan dated March 26, 2024, indicated one group therapy session per week and one individual session per week. There was no documentation of the client receiving individual therapy between April 7-27, 2024.
Client #6 was admitted on August 14, 2024, and discharged on November 14, 2024. The treatment plan dated September 9, 2024, indicated one group therapy session per week and one individual session per week. There was no documentation of the client receiving individual therapy between October 20-26, 2024.
This is a repeat ciation from the Novmeber 7, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director shall review all individual treatment plans to ensure clients are receiving counseling services as indicated in the record of services. Facility Director shall retrain staff on individual treatment plans and services. Facility Director shall review treatment plans and records of services on bi-weekly basis. This shall occur by 1/7/25. |