INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 27, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, BGI Brandywine 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:
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of one of eighteen personnel records reviewed, the project failed to provide documentation of at least one year of clinical experience for employee # 4.
Employee #4 was hired as a counselor on April 5, 202 and was still in this position at the time of the inspection. Based off the employees resume, employee # 4 only received six months of experience in a clinical position.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
This employee will have the correct job description for Counselor Assistant signed and in their personnel file by 6/19/20. The HR Director will review all resumes prior to hire to ensure all counseling staff have the correct job description based on their clinical experience. This will be reviewed monthly by the CEO to ensure compliance with this regulation. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of eighteen personnel records, the facility failed to provide documentation of four employees receiving a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Employee # 15 was hired as a detox BHA on March 22, 2018. HIV/AIDS TB/STD training was due on March 22, 2020.
Employee # 16 was hired as a UR specialist on May 14, 2018. HIV/AIDS TB/STD training was due on May 14, 2020.
Employee # 17 was hired as a BHA on May 1, 2018. HIV/AIDS TB/STD training was due on May 1, 2020.
Employee # 18 was hired as an Intake coordinator on May 2, 2018. HIV/AIDS TB/STD training was due on May 2, 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The four staff listed will attend HIV/AIDS and TB/STD training by 6/30/2020. In addition, HR will manage a spreadsheet to track all employees attendance at these trainings moving forward. HR will submit the spreadsheet to the Program Director quarterly to review for compliance with the regulation. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
|
Observations
Based on a review of eighteen personnel records, the facility failed to provide documentation of At least one-half of all training in this section shall be provided by trainers not directly employed by the project for two employees.
Employee # 3 was hired as a Clinical Supervisor on May 16, 2016 and was still in this position at the time of the inspection. Trainings provided by the project did not include trainings provided outside of the facility.
Employee # 14 was hired as a Clinical Supervisor on March 19, 2018 and was still in this position at the time of the inspection. Trainings provided by the project did not include trainings provided outside of the facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
HR will manage a spreadsheet to track training hours provided both internally and by a facilitator outside the project. HR will submit the spreadsheet to the Program Director quarterly to review for compliance with the regulation. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of twelve months of the facility's residential fire drill log, the facility failed to provide documentation of a fire drill being conducted the month of February 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Maintenance will submit a list of scheduled drills for the coming year to the Program Director by 6/18/2020. The Program Director will review drills during the monthly safety committee meeting to ensure compliance with this regulation. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of twelve months of the facility's partial program fire drill log, the facility failed to provide documentation of a fire drill being conducted the month of February 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Maintenance will submit a list of scheduled drills for the coming year to the Program Director by 6/18/2020. The Program Director will review drills during the monthly safety committee meeting to ensure compliance with this regulation. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of one of eighteen personnel records, the facility failed to provide documentation of an annual written individual staff performance evaluation for employee # 13.
Employee # 13 was hired as a counselor on December 23, 2018 and was still in this position at the time of the inspection. An annual performance evaluation was due no later than December 23, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This performance evaluation was completed on 6/4/2020. HR will send the list of performance evaluations due to the managers monthly and track completion of those performance evaluations. HR will report any missing evaluations to the Program Director for follow up to ensure compliance with the regulation. |