INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted February 6-7, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint 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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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client charts, the facility failed to ensure that treatment plans include the type and frequency of treatment and rehabilitation services in one out of five applicable client charts reviewed.
Client #2 was admitted on 10/9/2023 and was discharged on 12/12/2023. The master treatment plan dated 10/11/2023 was the only treatment plan in the chart and it was missing the individual counseling type and the frequency for individual counseling services.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
L1767- The CEO and Regional VP will re-educate clinical staff on the importance of documenting the type and frequency of treatment and rehabilitative services on the treatment plan. This training occurred on June 21, 2023 and February 22,2024
The clinical supervisors will monitor 10 charts for the next 3 months to ensure documentation of type and frequency of treatment. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client charts, the facility failed to ensure that treatment plans are reviewed and updated every 15 days in one out of five applicable client charts reviewed.
Client #2 was admitted on 10/9/2023 and was discharged on 12/12/2023. Per the facility's policy, client treatment plans are to be updated every two weeks. The master treatment plan was completed 10/11/2023. There were no treatment plan updates in the client chart.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
Previously identified on 12/23. POC submitted and accepted.
L1771- The CEO and Regional VP will re-educate clinical staff on the importance of completing the treatment plan update within the designated time frames. This training occurred on June 21, 2023 additional training on February 22 ,2024
If a clinical team member is unable to complete the treatment plan update within the designated time frame, he/she will notify his/her clinical supervisor so arrangements can be made for timely completion.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure treatment plan updates are completed timely. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 charts, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in one out of five applicable client charts reviewed.
Client #3 was admitted on 11/25/2023 and was discharged on 12/21/2023. The master treatment plan dated 11/30/2023 and the treatment plan updates on 12/7/23, 12/14/23 and 12/18/23 all indicated that the client was to receive group therapy 5-7 times per week and individual therapy 1 time per week. The last individual counseling note was 12/3/2023. There should have been two more individual counseling sessions documented in the chart.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
Previously identified on 12/23. POC submitted and accepted.
L1773- The clinical supervisors will re-educate clinical staff on the importance of assuring counseling services are provided according to the individual treatment and rehabilitation plan by February 22, 2024
The clinical supervisors will monitor 10 charts for the next 3 months to ensure counseling services are provided according to the individual treatment and rehabilitation plan. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client charts, the facility failed to ensure that counseling services are provided to clients on a regular and scheduled basis in two out of five applicable client charts reviewed.
Client #2 was admitted on 10/9/2023 and was discharged on 12/12/2023. The last individual counseling note was 10/18/2023. The client was to receive weekly individual counseling. There was no documentation of individual counseling services being provided after October 18, 2023.
Client #3 was admitted on 11/25/2023 and was discharged on 12/21/2023. The last individual counseling note was 12/3/2023. The client was to receive weekly individual counseling. There was no documentation of individual counseling services being provided after December 3, 2023.
This was discussed with facility staff at the time of the complaint investigation.
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Plan of Correction
L1775 - The clinical supervisors will re-educate clinical staff on the importance of conducting individual treatment sessions weekly. The clinical supervisors will monitor 10 charts for the next 3 months to ensure individual counseling services are provided. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance by February 22, 2024 |