INITIAL COMMENTS
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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 2, an abbreviated on-site inspection, conducted on November 16-19, 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, BGI of Brandywine 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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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
-Corrosion was observed on the three iron-frame staircases located outside of the Motel building.
-The cement steps on the staircases were cracking and broken in several place.
-A metal beam, outside of room 21 near the breezeway, displayed signs of deterioration.
-A wooden beam outside of room 21 was rotted.
-The railings, and other exposed metal surfaces had peeling paint and were corroded.
-The perimeter fence in the rear of the Mansion building had bent, broken and missing pickets and was leaning in several places.
This is a repeat citation from a complaint investigation conducted on October 7, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These deficiencies will be handled by an outside contractor. We are working with our Corporate process to obtain approval for the funds to complete this work. We anticipate having the work complete by 1/31/21 weather permitting. The Plant Operations Manager or designee will conduct weekly rounds for all buildings and the property and address any issues in a timely manner. Any potential repairs outside the score of our internal maintenance team will be brought to the attention of the Program Director and CEO. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
-A railing to the 2nd floor interior of the mansion house was not secured tightly to the wall.
-Basement bedroom #31 had insects in the light fixture and room #30 has ceiling tile stains.
-A bench outside the Barn was broken and had a sharp stone edge.
-The third-floor staff area and bathroom light fixtures had insects.
-The second-floor mansion staff refrigerator had food and drink spilled that needed to be cleaned.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/14/20 these deficiencies have been addressed. The Plant Operations Manager or designee will conduct weekly rounds of the facility grounds and buildings and address any concerns within a reasonable timeframe. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
Group rooms on second floor of the Barn did not have operable sound machines and sessions could be heard in the hallway.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/11/20 sound machines are available and in use during all process group sessions. The Clinical Supervisors will conduct weekly rounds to ensure we remain in compliance. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide adequate ventilation in the following detox bathrooms: #35, 36, 38, 47, and 48.
This is a repeat citation from a complaint investigation completed on October 7, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our HVAC vendor has checked the ventilation system in the Detox/Main building. We have written confirmation that the rooms in this building have a central exhaust system ducted to each bathroom that operates 12/7 and is fully operational at this time. Each room was inspected and all exhausts are working properly. The Plant Operations Manager or designee will check the exhaust system/fans in resident rooms during his weekly rounds to ensure all units are operational. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
Motel room # 14 had what appeared to be mildew on the shower ceiling.
All motel rooms had ceiling tiles replaced and painting had been recently done, rooms still had an odor that resembled mildew.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The shower ceiling in room 14 was addressed and has no evidence of mildew as of 12/14/20. The Plant Operations Manager or designee will conduct weekly rounds of all resident rooms and address any concerns within a reasonable timeframe. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility failed to keep the kitchen dry stock area free of rodent infestation. There were what appeared to be mouse droppings observed in this area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Dietary Manager will meet with our outside vendor regarding ongoing pest control in the kitchen area. The Dietary Manager will conduct a weekly inspection to ensure compliance. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection, the facility failed to limit smoking to designated smoking areas. This was observed as cigarette butts were on the ground in multiple areas of the facility grounds.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor or designee will re-emphasize the smoking rules to the resident population during daily roll calls. The Clinical Director will conduct weekly rounds to ensure compliance with this standard. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility failed to provide adequate light on the interior stairway to the basement bedrooms in the Mansion house.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A light has been installed in this stairway. The Plant Operations Manager or designee will complete weekly building rounds and address any issues in a reasonable timeframe. Any fire safety concerns will be reviewed during the monthly safety committee meeting. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on one of twenty-five client records reviewed, the facility failed to provide a dated signature on an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 1 was admitted to detox on November 14, 2020 and was still active at the time of the inspection. An informed and voluntary consent form to an emergency contact was not signed or dated by a witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Admissions Director will retrain all departments on accurate completion of releases of information by 12/31/20. Training will re-occur on a quarterly basis. Medical Records will review charts on a monthly basis to ensure compliance. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on seven of twelve client records reviewed, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. Also, the narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
Client # 1 was admitted on November 14, 2020 and was still active at the time of the inspection. The face to face determination of physiological dependence for one year and current dependence was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 2 was admitted on November 13, 2020 and was still active at the time of the inspection. The face to face determination of physiological dependence for one year and current dependence was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 3 was admitted on November 12, 2020 and was still active at the time of the inspection. The face to face determination of physiological dependence for one year and current dependence was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 4 was admitted on November 12, 2020 and was still active at the time of the inspection. The face to face determination of physiological dependence for one year and current dependence was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 7 was admitted on October 24, 2020 and was still active at the time of the inspection. The face to face determination of physiological dependence for one year and current dependence was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 9 was admitted on November 3, 2020 and was still active at the time of the inspection. The face to face determination of physiological dependence for one year and current dependence was not being completed by a narcotic treatment physician but instead by nurse practitioner.
Client # 11 was admitted on May 30, 2020 and was still active at the time of the inspection. The face to face determination of physiological dependence for one year and current dependence was not being completed by a narcotic treatment physician but instead by nurse practitioner.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The narcotic treatment physician shall complete the face to face determination for opioid dependence. The Program Director or designee will review charts on a monthly basis to ensure compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on six of twelve client records reviewed, the facility failed to have a narcotic treatment physician determine the initial dosage and schedule in client records # 1, 2, 3, 4, 7, and 11.
Client # 1 was admitted on November 14, 2020 and was still active at the time of the inspection. The initial dose and schedule was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 2 was admitted on November 13, 2020 and was still active at the time of the inspection. The initial dose and schedule was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 3 was admitted on November 12, 2020 and was still active at the time of the inspection. The initial dose and schedule was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 4 was admitted on November 12, 2020 and was still active at the time of the inspection. The initial dose and schedule was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 7 was admitted on October 24, 2020 and was still active at the time of the inspection. The initial dose and schedule was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
Client # 11 was admitted on May 30, 2020 and was still active at the time of the inspection. The initial dose and schedule was not being completed by a narcotic treatment physician but instead by the certified nurse practitioner.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The narcotic treatment physician shall determine the initial dosage and schedule for Methadone. The Program Director or designee will review charts on a monthly basis to ensure compliance. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on four of nineteen patient records reviewed, the facility failed to provide documentation of follow-up information as indicated by the facilities policy and procedure manual. The policy and procedure manual indicates that a follow-up is to occur 1 week after a transfer or thirty days of a successful or against facility advice discharge.
Patient # 10 was admitted on October 19, 2020 and discharged on November 17, 2020. There was no documentation of a follow-up in the client record.
Patient # 11 was admitted on May 30, 2020 and discharged on June 17, 2020. There was no documentation of a follow-up in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/4/21 Medical Records staff will conduct follow up calls with aftercare providers to determine if the resident admitted to the aftercare program post discharge from Bowling Green. The Program Director or designee will review charts on a monthly basis to ensure compliance. |