INITIAL COMMENTS
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This report is a result of an on-site complaint investigation and provisional license follow up conducted on August 3-5, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation and follow up, BGI of 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 investigation:
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Plan of Correction
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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 that was conducted on August 3, 2026, and August 5, 2026, the facility failed to keep the grounds clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees, and visitors.
The door of the Barn, which is located at the bottom right when facing the building, was observed to have a cracked window.
The two washing machines, which are located inside the laundry room of the Mansion, were observed to have a black mold-like substance on the plastic edges on the outside rim of the tubs.
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Plan of Correction
The organization has cleaned all the washing machines and ensured all unidentified substances have been removed. Inspection of the interior of washing machines has been added to the monthly RM inspection checklist to ensure ongoing compliance. Monthly Inspection findings are reported to the monthly RQM Committee Meeting. The Director of Facility Operations is responsible for the implementation of this plan of correction.
The facility has ordered a replacement entry door, including new glass, for the 2nd floor of the barn. The new door will be installed by 9/30/26. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of patient records, and the Medication Management policy, the facility failed to provide documentation of medication being provided as prescribed by a physician in one of four records reviewed.
Medication Management policy - If a client does not report for medication or in some other way refuse a dose of their medication, an NS or R will be written in the space provided on the MAR where documentation of the medication administration would have occurred. The NS or R will also be written in at the specified location on the MAR with no show or refused spelled out to denote its meaning. The medication nurse on each shift, or any nursing staff that administers medication on that shift is responsible for all entries on the MAR.
Patient # 2 was admitted for residential services on April 16, 2026, and discharged on June 12, 2026. This patient was prescribed 20 mg of a medication to be taken at bedtime. The Medication Administration Record for this medication was blank on May 10, 27, & 28, and June 5 & 6. This patient was prescribed 40 mg of a medication to be taken at bedtime. The Medication Administration Record for this medication was blank on June 5 and June 6. This patient was prescribed 40 mg of another medication to be taken at bedtime. The Medication Administration Record for this medication was blank on May 10, 27, & 28. This patient was prescribed 40 mg of a medication to be taken once daily. The Medication Administration Record for this medication was blank on May 4 & 23. This patient was prescribed 10 mg of a medication to be taken once daily. The Medication Administration Record for this medication was blank on May 23, 28, and 29. This patient was prescribed 50mg/200mg/25mg of a medication to be taken once daily. The Medication Administration Record was blank on May 23, 2026.
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Plan of Correction
All Nursing staff will be re-educated on MAR documentation policy for both scheduled and PRN medication. Re-education will be completed for all nursing staff by 9/10/26. Documentation of this re-education will be maintained in individual employee files. DON or designee will audit no less than 10 MARs monthly to monitor for compliance. Audit findings will be submitted to the RQM Committee monthly for review. The DON and Risk Manager are responsible for the implementation of this plan of correction.
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