INITIAL COMMENTS
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This report is a result of an on-site investigation of an unusual incident conducted on April 20-21, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site investigation, BGI of Brandywine, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of video footage dated April 9, 2026, and the Nursing Protocol: Unresponsive Patient, the facility failed to follow its written procedures for the management of treatment/rehabilitation services for clients.Per the Nursing Protocol: Unresponsive Patient, if patient has no pulse and no respirations, have a nursing staff member call 911 and initiate CPR. A patient was found unresponsive at 19:48:40 and CPR was not initiated until 19:59:14.
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Plan of Correction
BGB staff will receive refresher training on Emergency Response Protocol relating to non-responsive person, ensuring staff understand how to determine if a patient is in distress and when to start CPR. The Director of Nursing or his/her designee is responsible for ensuring this training is complete for all staff by 6/15/26. BGB will run medical emergency drills twice per year at a minimum. POC compliance will be monitored by the BGB Leadership team.
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709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
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Observations
During an investigation conducted on April 20-21, 2026, the facility failed to provide the authorized Department representative with full and free access to records of the facility and its clients. Video footage was requested for April 9, 2026, starting at 7 am and ending after a client was transported out of the building. This video footage was requested on April 20, 2026. The facility was unable to supply this video footage, even though they are to have the capability to review footage for two weeks from the date of the incident.
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Plan of Correction
On 4/20/26: RM contacted the camera vendor for assistance in retrieving the video and was informed that retrievability is determined by the amount of storage available on their server. BGB has engaged the vendor to review current technology and contractual requirements for retrievability. BGB's operational leadership is responsible for completion of this POC by 6/30/26. BGB's incident investigation protocols will be revised to ensure all pertinent supporting evidence is secured in a timely manner and available for future review. BGB's Risk Manager is responsible for completion of this poc by 6/15/26. BGB's Risk Manager and Operational leadership are responsible for monitoring compliance of this POC. BGB is unable to retrieve the missing footage. |