INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in January, per the facility's policy, in six out of six records reviewed.Employee #1 was hired on June 1, 2025, as a project director and was still in the position as of the date of the inspection. There was no documentation that an individual training plan was completed. Employee #2 was hired on June 1, 2025, as a facility director and was still in the position as of the date of the inspection. The individual training plan was not documented until May 15, 2026. Employee#3 was hired on September 20, 2025, as a clinical supervisor and was still in the position as of the date of the inspection. The individual training plan was not documented until May 6, 2026. Employee # 4 was promoted on January 12, 2026 to the clinical supervisor position and was still in the position as the time of the inspection. The individual training plan was not documented until May 8, 2026. Employee # 5 was hired on January 29, 2025, as a counselor and was still in the position at the time of the inspection. The individual training plan was not documented until November 31, 2025. Employee #6 was hired on June 12, 2024, as a counselor and was still in the position at the time of the inspection. The individual training plan was not documented until May 9, 2026 and did not include documentation that it developed with input from both the employee and the supervisorThis is a repeat citation from April 25, 2025 licensing inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All missing training plans have been
completed and added to the
employee file. The organization has
provided refresher training to all
managers to ensure timely
completion of annual trainings plans,
to be submitted to HR no later than
1/31 of each year. The Organization
has implemented a compliance
monitoring schedule which includes
quarterly audits of HR files for all
new hires. Audit findings will be
submitted to the Risk/Quality
Committee in the month following
completion of the scheduled audit.
The Director of HR is responsible for
implementation of these corrective
action. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received at least 6 hours of HIV/AIDS and at least 4 hours of tuberculous, sexually transmitted diseases and other health-related topics training, using a Department approved curriculum, within the regulatory time frames in two out of two personnel records reviewed. Employee # 4 was hired on September 9, 2020, as a counselor and promoted to a clinical supervisor on January 12, 2026, and was still in the position as the time of the inspection. The tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than September 9, 2021; however, there is no documentation that the employee received the training as of the date of the inspection. Employee #5 was hired on January 29, 2025, as a counselor and was still in the position at the time of the inspection. The HIV/AIDS and tuberculosis, sexually transmitted diseases, and other related health topics training were due no later than January 29, 2026; however, there is no documentation that the employee received either training as of the date of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The organization has adopted a
training curriculum that captures all
elements of PA 704.11(c). All staff
currently out of compliance will have
this training completed by 7/30/2026.
This training has also been
incorporated into the Organizations
standard New Hire Orientation
curriculum to ensure compliance
moving forward. The Organization
has implemented a compliance
monitoring schedule which includes
quarterly audits of HR files for all
new hires. Audit findings will be
submitted to the Risk/Quality
Committee in the month following
completion of the scheduled audit.
The Director of HR is responsible for
implementation of these corrective
actions |
705.9 (4) (ii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one out of two applicable records reviewed. Employee #3 was hired on September 20, 2025, as a clinical supervisor and was still in the position as of the date of the inspection. Employee #3 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training occurred; however, there is no date as to when the employee received the training to confirm it was completed prior to working a shift. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The identified staff will re-take the
Organization's Fire Safety Training
by 7/30/26 to create fully
documented training completion.
The Organization will ensure all
training documentation is completed
accurately and thoroughly. The
Organization has implemented a
compliance monitoring schedule
which includes quarterly quality
assurance audits of HR files for all
new hires and ongoing training
audits for existing employees. Audit
findings will be submitted to the
Risk/Quality Committee in the month
following completion of the
scheduled audit. The Director of HR
is responsible for implementation of
these corrective actions. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in one out of two applicable records reviewed. Employee #3 was hired on September 20, 2025, as a clinical supervisor and was still in the position as of the date of the inspection. Employee #3 was to be instructed in the use of a fire extinguisher upon employment. Documentation in the records shows the training occurred; however, there is no date as to when the employee received the training to confirm it was completed upon employment.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The identified staff will re-take the
Organization's Fire Safety Training,
including the P.A.S.S. principles by
7/30/26 to create fully documented
training completion. The
Organization will ensure all training
documentation is completed
accurately and thoroughly. The
Organization has implemented a
compliance monitoring schedule
which includes quarterly quality
assurance audits of HR files for all
new hires and ongoing training
audits for existing employees. Audit
findings will be submitted to the
Risk/Quality Committee in the month
following completion of the
scheduled audit. The Director of HR
is responsible for implementation of
this corrective action |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client that included written documentation of the type and frequency of treatment and rehabilitation services in seven out of seven records reviewed. Client #1 was admitted on March 27, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 18, 2026, that did not document the type or frequency of treatment and rehabilitation services.Client #2 was admitted on April 22, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 28, 2026, that did not document the type or frequency of treatment and rehabilitation services.Client #3 was admitted on April 7, 2026, and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 18, 2026, that did not document the type or frequency of treatment and rehabilitation services.Client #4 was admitted on July 28, 2025, and discharged on August 15, 2025. A comprehensive treatment plan was developed on July 30, 2025, that did not document the type or frequency of treatment and rehabilitation services. Client #5 was admitted on September 19, 2025, and discharged on November 3, 2025. A comprehensive treatment plan was developed on September 23, 2025, that did not document the type or frequency of treatment and rehabilitation services.Client #6 was admitted on November 22, 2025, and discharged on January 17, 2026. A comprehensive treatment plan was developed on November 24, 2025, that did not document the type or frequency of treatment and rehabilitation services.Client #7 was admitted on March 10, 2026, and discharged on April 23, 2026. A comprehensive treatment plan was developed on March 13, 2026, that did not document the type or frequency of treatment and rehabilitation services.This is a repeat citation from the April 25, 2025 inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide
refresher training to all clinical staff
regarding accurate completion of the
Master Treatment Plan, including
identified type and frequency of
treatment and rehabilitation services
to be provided. Documentation of
this training will be maintained in the
employees' HR files. The
Organization has incorporated
monthly auditing of identified type
and frequency of
treatment/rehabilitation services
included in the MTP, into the
Annual Compliance Monitoring
Schedule. Audit findings will be
submitted for review to the
Risk/Quality Management
Committee in the month following
the scheduled audit. The Director of
Clinical Services, Director of HR and
the Risk Manager are responsible for
implementation of this corrective action. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment plans at least every 30 days in four out of seven client records reviewed.Client #1 was admitted on March 27, 2026, and was still active at the time of the inspection. A treatment plan was documented on April 18, 2026, and the next update was due no later than May 18, 2026; however, it was not documented until May 28, 2026. Client #2 was admitted on April 22, 2026, and was still active at the time of the inspection. A treatment plan was documented on April 28, 2026, and the next update was due no later than May 28, 2026; however, there was no documentation that one was completed.Client #6 was admitted on November 22, 2025, and discharged on January 17, 2026. A treatment plan was documented on December 11, 2025, and the next update was due no later than January 10, 2026; however, it was not documented until January 15, 2026. Client #7 was admitted on March 10, 2026, and discharged on April 23, 2026. A treatment plan was documented on March 13, 2026, and the next update was due no later than April 12, 2026; however, there was no documentation that one was completed. This is a repeat citation from the April 25, 2025 licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization will provide
refresher training to all clinical staff
regarding timely ongoing
reviews/updates of the Master
Treatment Plan, as dictated per the
Organization's policy.
Documentation of this training will
be maintained in the employees' HR
files. The Organization has
incorporated monthly auditing of
timely reviews/updates of the
Master Treatment Plan the into the
Annual Compliance Monitoring
Schedule. Audit findings will be
submitted for review to the
Risk/Quality Management
Committee in the month following
the scheduled audit. The Director of
Clinical Services, Director of HR and
the Risk Manager are responsible for
implementation of these corrective
actions |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of the client records, the facility failed to ensure that counseling was provided to a client on a regular and scheduled basis to include individual counseling, at least twice weekly in six out of seven records reviewed. Client #1 was admitted on March 27, 2026, and was still active at the time of the inspection. The weeks of April 6, 13, 20, 27, May 4, 11, 18, 31 and June 7, 2026, did not have documentation of two individual counseling sessions. Client #2 was admitted on April 22, 2026, and was still active at the time of the inspection. The weeks of April 27, May 4, 11, 18, 25, June 1 and 7, 2026, did not have documentation of two individual counseling sessions. Client #3 was admitted on April 7, 2026, and was still active at the time of the inspection. The weeks of April 13, 20, 27, May 4, 11, 18, 25, June 1 and 8, 2026, did not have documentation of two individual counseling sessions. Client #5 was admitted on September 19, 2025, and discharged on November 3, 2025. The weeks of September 22, 29, October 6, 13, 20 and 27, 2026, did not have documentation of two individual counseling sessions. Client #6 was admitted on November 22, 2025, and discharged on January 17, 2026. The weeks of November 24, December 1, 8, 15, 22, 29, 2025 and January 5 and 12, 2026, did not have documentation of two individual counseling sessions. Client #7 was admitted on March 10, 2026, and discharged on April 23, 2026. The weeks of March 9, 16, 23, 30, April 6, 13 and 20, 2026, did not have documentation of two individual counseling sessions. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Organization will provide
refresher training to all clinical staff
regarding required frequency of individual counseling sessions twice per week at a minimum. Documentation of this training will be maintained in the employees' HR files. The Organization has incorporated monthly auditing of
timely reviews/updates of the Master Treatment Plan the into the Annual Compliance Monitoring Schedule. Audit findings will be submitted for review to the Risk/Quality Management Committee in the month following the scheduled audit. The Director of Clinical Services, Director of HR and the Risk Manager are responsible for implementation of these corrective
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709.83(a)(4) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual that included information relative to the client ' s involvement with the project including case consultations in four out of four applicable client records. Client #4 was admitted on July 28, 2025, and discharged on August 15, 2025. There were no case consultations documented in the closed client record. Client #5 was admitted on September 19, 2025, and discharged on November 3, 2025. There were no case consultations documented in the closed client record. Client #6 was admitted on November 22, 2025, and was discharged on January 17, 2026. There were no case consultations documented in the closed client record. Client #7 was admitted on March 10, 2026, and discharged on April 23, 2026. There were no case consultations documented in the closed client record. This is a repeat citation from the April 25, 2025 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has adopted and
implemented a Case Consultation &
Transition Plan policy and
documentation format. Staff will be
trained on and began using this format
on 7/15/26. The Organization has
incorporated monitoring of the
appropriate documentation of Case
Consultation into the Annual
Compliance Monitoring Schedule.
Audit findings will be submitted to
the Risk/Quality Committee in the
month following completion of the
scheduled audit. The Director of
Clinical Services is responsible for
implementation of this corrective
action |
709.83(a)(6) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which included aftercare information completed prior to discharge, per the facility's policy, in three out four applicable records reviewed. Client #5 was admitted on September 19, 2025, and discharged on November 3, 2025. There was no documentation in the client record that aftercare information was completed prior to discharge. Client #6 was admitted on November 22, 2025, and discharged on January 17, 2026. There was no documentation in the client record that aftercare information was completed prior to discharge. Client #7 was admitted on March 10, 2026, and discharged on April 23, 2026. There was no documentation in the client record that aftercare information was completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has provided
refresher training to all clinical staff regarding the requirements for completion of Aftercare Plans, inclusive of specific aftercare information for all patients prior to the date of discharge.
The Organization has incorporated
monthly auditing of timely
completion of patient aftercare plans into the Annual Compliance Monitoring
Schedule. Audit findings will be
submitted to the Risk/Quality
Committee in the month following
completion of the scheduled audit.
The Director of Clinical Services and
Risk Manager is responsible for
implementation of these corrective
actions. |
709.83(a)(10) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which included information relative to the client's involvement with the project, including a discharge summary within seven days of discharge, per the facility ' s policy, in three out of four applicable records reviewed. Client #5 was admitted September 19, 2025, and discharged on November 3, 2025. A discharge summary was due no later than November 10, 2025; however, there was no documentation that one was completed. Client #6 was admitted on November 22, 2025, and discharged on January 17, 2026. A discharge summary was due no later than January 24, 2026; however, there was no documentation that one was completed. Client #7 was admitted on March 10, 2026, and was discharged on April 23, 2026. A discharge summary was due no later than April 30, 2026; however, there was no documentation that one was completed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has provided
refresher training relating to required completion of discharge summaries within 7 days of discharge.
The Organization has incorporated
monthly auditing of timely
completion of discharge summaries into
the Annual Compliance Monitoring
Schedule. Audit findings will be
submitted to the Risk/Quality
Committee in the month following
completion of the scheduled audit.
The Director of Clinical Services and
Risk Manager is responsible for
implementation of these corrective
action |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, that included a follow-up contact within thirty days, per the facility ' s policy, in three out of four applicable records reviewed. Client #4 was admitted on July 28, 2025, and discharged on August 15, 2025. A follow up contact was due no later than September 15, 2025; however, there was no documentation that one occurred. Client # 6 was admitted on November 22, 2025, and discharged on January 17, 2026. A follow up contact was due no later than February 17, 2026; however, it was not completed until February 25, 2026. Client # 7 was admitted on March 10, 2026, and discharged on April 23, 2026. A follow contact was due no later than May 23, 2026; however, there was no documentation that one occurred. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Organization has provided
refresher training for timely completion of patient follow-up post discharge.
The Organization has incorporated
monthly auditing of timely
completion of patient follow-up into
the Annual Compliance Monitoring
Schedule. Audit findings will be
submitted to the Risk/Quality
Committee in the month following
completion of the scheduled audit.
The Director of Clinical Services and
Risk Manager is responsible for
implementation of these corrective
action |