INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-19, 2019 of BGI of Brandywine, Inc. by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, 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 inspection:
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Plan of Correction
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection of the dumpster area on July 16-19, 2019, it was observed that the facility failed to prevent the penetration of inspection and rodents by not maintaining closed dumpsters. The licensing specialist observed the side door of the dumpster to be open each day that the licensing specialist was on site.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
A sign was placed on the dumpster to remind people to close the side door of the dumpster. Housekeeping, Maintenance and Dietary staff are monitoring this daily. We will look to replace the dumpster with one that does not have the side door by 9/30/19. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical site inspection conducted on July 17, 2019, the facility failed to maintain slip-resistant surfaces in showers. It was observed that in the showers of rooms # 10, 11, 13, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 28 and 29 there were no slip-resistant surfaces.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Non-slip strips were installed in the showers on 7/29/19. Maintenance staff will monitor the showers during their weekly room inspections to ensure continued compliance. |
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 site inspection on July 17, 2019, it was observed that the facility failed to maintain each bathroom in a functional, clean and sanitary manner as evidence by the following:
1) Black mold was observed in the showers of seven client bathrooms. Rooms affected were #13, 15, 17, 19, 20, 23, and 26.
2) Showers were observed to have dirt ingrained on the surface of the walls, floors and door areas. The rooms affected were client rooms #'s 12, 14, 16, 21, 22, 23, 24, 25, 26, 27, 28, 29, 36, and 42. In addition, the following showers areas were also deemed unsanitary: Bath 1, Bath 2, Bath 4, Bath 5, and both baths in the expansion area by the observation of dirt on the walls, floors and door areas.
3) Sharp edges were observed to be protruding from the bathroom baseboard heating unit causing a hazard in client rooms # 23 and 29.
4) A bathroom vanity door had peeling paint in client room #21.
5) A bathroom vanity had a broken drawer in client room #27.
6) Bathroom 4 was observed to have a dirty shower curtain.
These findings were reviewed with facility staff during the licensing inspection process. This is a repeat citation from the July 16-19, 2018 inspection.
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Plan of Correction
1 and 2)Housekeeping staff completed a thorough cleaning of all showers as of 8/2/19.
3)The sharp edges on the baseboard heaters were fixed on 7/18/19.
4)The vanity door panel will be painted by 8/16/19.
5)The broken vanity drawer was fixed on 7/18/19.
6)All of the shower curtains were replaced as of 8/7/19.
Maintenance staff will complete weekly inspections of all bathrooms to ensure continued compliance.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
A review of the July 2018 through June 2019 fire drill logs was conducted during the onsite inspection July 16-19, 2019. The facility failed to conduct unannounced drills during sleeping hours at least every six months. An unannounced fire drill during sleeping hours was conducted on October 31, 2018 with the next one being completed on May 29, 2019. These two sleeping fire drills were completed seven months apart.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A yearly calendar of scheduled fire drills is in place effective 8/1/19 to ensure that drills are conducted on each shift and during sleeping hours every six months. Compliance with the schedule will be monitored during the monthly safety committee meeting. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records on July 16-19, 2019, the facility failed to ensure that the clients were not made aware of all of their client rights. The Patient Rights document signed by the clients did not state that the facility may not discriminate based on "creed", in nineteen of twenty-one records reviewed. The client records with the missing information was #'s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20 and 21.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Consent to Treatment was previously revised in use as of 7/1/19. The correct form will be reviewed and signed by all current residents. The Admissions Director will review 10 charts monthly to ensure compliance. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The facility failed to adequately document the administration of medication according to physician's orders in three client medication administration records reviewed. During a physical site inspection on July 17, 2019, a review of the current client medication administration records was conducted. For clients #22, 23, and 24, only their administration medication records were reviewed and not their entire client record.
1) Client #22 was admitted on July 8, 2019 and was still active at the time of the inspection. The medication administration record did not have documentation of the client receiving the following medications on July 11, 2019:
(a) 7:00am administration of a one time daily dose of multivitamin.
(b) 7:00 am administration of a one time daily dose of Vitamin B Complex
(c) 7:00 am administration of one time daily dose of N-acetylcysteine
2) Client #23 was admitted on June 23, 2019 and was still active at the time of the inspection. The medication record did not have documentation of the client receiving the following medications on July 3, July 5 and July 12, 2019:
(a) 7:00am administration of a one time daily dose of multivitamin.
(b) 7:00 am administration of a one time daily dose of Vitamin B Complex
(c) 7:00 am administration of one time daily dose of N-acetylcysteine
Client #24 was admitted on June 25, 2019 and was still active at the time of the inspection. The medication record did not have complete documentation of the client receiving the following medications on July 12, 2019. The medication administration record showed the client was a "no show" during the medication administration time frame. In reviewing the client's record, there was no documentation of staff attempting to engage the client to give the medication and/or if the client refused, staff contacting the ordering physician due to the nature of the medications. During an interview with the Director of Nursing and the Chief Operations Officer, both acknowledged documentation was not complete in the client's record regarding this administration of medication.
(a) 7:00am administration of a 20 mg dose of Prozac
(b) 7:00am administration of Fluticasone Propionate Nasal Spray
(c) 7:00am and 5:00pm administration of a 100mg of Gabapentin
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director will change the daily vitamin orders to PRN upon admission/transition to Rehabilitation level of care. The Director of Nursing will re-educate the nursing staff on proper documentation on a client's MAR when a client is in the hospital and/or if the client refuses any medication. The doctor will be informed if a client refuses a medication for 3 consecutive days. The DON will re-educate the nurses on the importance of proper documentation overall during the monthly nursing meetings on 8/19/19. The DON will review 10 charts monthly to ensure continued compliance. |