INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 20-21, 2026, 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the Progressive Discipline and Patient Abuse procedures inside the Employee Handbook, and a review of employee files, the facility failed to follow its written procedures. In the Employee Handbook, it states the company has a zero-tolerance policy prohibiting patient physical or emotional abuse. This includes using foul or hostile language or shouting at a patient. Disciplinary action may take the form of counseling, verbal or written warnings, suspension, or termination, depending on the number and frequency of past violations and the seriousness of the offense.Employee # 4 was hired as a Counselor on 10/22/25 and ended employment on 4/19/26. Written grievances related to patient abuse were submitted on 1/26/26, 3/2/26, 3/4/26, and 3/24/26 for Employee # 4. There was no documentation of the grievance dated 1/26/26 being discussed with the employee. A Performance Improvement Plan was documented on 3/11/26 and Employee # 4 was assigned training courses to complete within 30 days. A Coaching Record was dated 3/25/26 and the employee and their supervisor were to ensure completion of all outstanding assignments by 4/15/26. These assigned training coursese were not completed as of the employee's departure on 4/19/26.
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Plan of Correction
BGB assigned 3 training courses to employee #4 on 3/11/26 at the conclusion of our internal investigation. The assigned trainings were completed by employee #4 on4/7/26. Supervisors will receive refresher training to ensure that all employee disciplinary actions including assigned trainings, are followed up on in a timely manner and certificates of completion are submitted to Human Resources by the designated due date. The Director of Human Resources is responsible for implementation and compliance monitoring of this POC by 6/10/26. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of patient records, grievances, and the Patient Grievance, Advocates, Rights and Responsibilities policy, the facility failed to follow its patient grievance procedures.Per the Patient Grievance, Advocates, Rights and Responsibilities policy, the primary counselor or program coordinator will address the grievance during the first business day to ensure that proper attention is given to the matter and that a mutually satisfactory resolution is achieved. The patient will receive a response concerning the incident within two business days. Any grievance, which impacts a patient's treatment, will be documented in the patient's medical record. A written grievance dated 1/9/26 had no documentation of a mutually satisfactory resolution. A letter to the patient acknowledging receipt of the grievance form was dated 1/15/26.A written grievance dated 1/19/26 had no documentation of a mutually satisfactory resolution. A written grievance dated 1/26/26 had no documentation of a mutually satisfactory resolution.Patient # 5 handed in a written grievance on 3/24/26. This was not documented in the patient's medical record.
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Plan of Correction
BGB has revised its Patient Grievance, Advocates, Rights and Responsibilities policy to ensure our practice and policy are aligned and ensure appropriate follow up and documentation as indicated. Staff will receive refresher training on this policy by 6/15/26. The Risk Manager is responsible for implementation of this POC. The BGB Leadership team is responsible for ongoing compliance monitoring. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of client grievances, the facility failed to file a written Unusual Incident Report with the Department within 48 hours of an unusual incident which includes complaints of patient abuse (physical, verbal, sexual and emotional). The facility was in receipt of complaints of patient abuse on 1/15/26, 1/19/26, 1/26/26, 2/2/26, 3/2/26 and 3/4/26. The facility did not file a written Unusual Incident Report with the Department for these complaints.
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Plan of Correction
Indicated BGB staff will be re-educated on DDAP Incident Reporting requirements and will ensure 100% of reportable incidents are submitted to the department within 48 hours of receipt of the report. 100% of significant patient events are reviewed by BGB's leadership team daily. The Risk Manager is responsible for implementation of this POC by 5/30/26. The RQM Committee is responsible for ongoing compliance with this POC. |