INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on July 21, 2021 through July 22, 2021 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, 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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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 employee files and the facilities Staffing Requirement Facility Summary Report the facility failed to ensure all staff completed mandatory 6 hours of HIV/AIDS and 4 hours TB/STD trainings within regulatory time frame.
Employee #14 was hired as a Behavioral Tech on May 17, 2017. The HIV/AIDS training and the TB/STD training were due to be completed no later than May 17, 2019. There was no documentation of the completed trainings at the time of the inspection.
Employee #15 was hired as a Behavioral Tech on March 25, 2019. The HIV/AIDS training and the TB/STD training were due to be completed no later than March 25, 2021. There was no documentation of the completed trainings at the time of the inspection.
Employee #16 was hired as a Behavioral Tech on May 1, 2018. The HIV/AIDS training and the TB/STD training were due to be completed no later than May 1, 2020. There was no documentation of the completed trainings at the time of the inspection.
This is a repeat citation from the off-site annual renewal inspection conducted on May 29, 2020.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The following information was missed being inputted on the SRFSR: employee #14 had HIV training on 4/25/19 and STD/TB training on 11/17/18; employee #15 had HIV training on 12/29/20 and STD/TB training on 12/28/20; employee #16 had HIV training on 12/29/20 and will be scheduled for STD/TB training upon return from FMLA. The HR Director will maintain a spreadsheet tracking hire dates and training attendance dates for all employees. The spreadsheet will be reviewed by the HRD and CEO twice a year to ensure compliance with this regulation. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection conducted on July 22, 2021, the facility failed maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
- The railings, and other exposed metal surfaces had peeling paint and were corroded.
- The perimeter fence in the rear of the Mansion building had bent, broken and missing pickets and was leaning in several places.
This is a repeat citation from the complaint investigation conducted on October 7, 2020 and the annual onsite renewal inspection conducted on November 19, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The railings and other exposed metal surfaces with peeling paint have been addressed and repainted as of 8/10/21.
The broken areas of the perimeter fence were repaired as of 8/4/21.
The Plant Operations Manager or designee will conduct weekly rounds for all buildings and grounds and address any issues in a timely manner. Any potential repairs outside the scope of our internal maintenance team will be brought to the attention of the CEO. |
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 conducted on July 22, 2021, the facility failed to 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. There was a cracked pane of glass on an interior door leading to the women's bedroom located in the basement area of the Mansion building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The cracked window pane will be repaired as of 8/12/21.
The Plant Operations Manager or designee will conduct weekly rounds for all buildings and grounds and address any issues in a timely manner. Any potential repairs outside the scope of our internal maintenance team will be brought to the attention of the CEO. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on July 22, 2021, the facility failed to maintain all counseling areas with furnishings which are in good repair as there were four counselor offices in the Barn building that had furniture with observable peeling. Additionally, there was one counselors office that had a couch with an arm rest with rips/tears that were deep enough to show interior material and wood of the couch.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All ripped or torn furniture will be removed and replaced by 9/15/21. The Plant Operations Manager or designee will conduct monthly rounds for all offices and remove any furniture in disrepair. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on July 22, 2021, the facility failed to ventilate all toilet and wash rooms with an exhaust fan or window. Bedrooms #27 and #29 in the Motel building had inoperable exhaust fans in their respective bathrooms.
This is a repeat citation from the complaint investigation conducted on October 7, 2020 and the annual onsite renewal inspection conducted on November 19, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The exhaust fan in room 27 was replaced on 7/23/21 and the exhaust fan in room 29 was replaced on 8/10/21.
The Plant Operations Manager or designee will conduct weekly rounds for all buildings and grounds and address any issues in a timely manner. Any potential repairs outside the scope of our internal maintenance team will be brought to the attention of the CEO. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection conducted on July 22, 2021, the facility failed to provide toilet paper at each toilet at all times. Bathroom #4 in the Mansion building did not have toilet paper in it at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients are notified during orientation that if they run out of toilet paper it is available in the tech office or from housekeeping. Housekeeping staff will ensure that all bathrooms have a supply of toilet paper on a daily basis. The Housekeeping Supervisor will complete weekly rounds to ensure compliance with this regulation.
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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 plant inspection conducted on July 22, 2021, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The following items were obsrved:
-Motel room #23 had what appeared to be mildew on the shower pan.
-The sink in the Mansion building's basement women's bedroom was not draining properly at the time of the inspection.
-The bathroom in bedroom #29 of the Motel building had a shower door the did not open or close properly.
-The male bathroom in the new rehabilitation center, adjacent to the detox area, had a faucet that was loose.
This is a repeat citation from the annual onsite renewal inspection conducted on November 19, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The shower in room 23 was cleaned on 7/22/21.
The drain in the sink in the Mansion basement bathroom was repaired on 7/27/21.
The shower door in room 29 was repaired on 7/26/21.
The faucet in the rehab hallway in the Main building was repaired on 8/3/21.
The Plant Operations Manager or designee will conduct weekly rounds for all bathrooms and address any issues in a timely manner. Any potential repairs outside the scope of our internal maintenance team will be brought to the attention of the CEO. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on July 22, 2021, the facility failed to limit smoking to the designated smoking areas. There were cigarette butts located outside on the ground in multiple areas that were not designated as smoking areas. Additionally, the Motel building area had a significant amount of discarded cigarette butts directly outside the rooms and on the stairwell.
This is a repeat citation from the annual renewal inspection conducted on November 19, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be re-educated on the importance of limiting client smoking to the designated smoking areas. The designated smoking areas will be reviewed daily with clients during the 9:30am community meeting. Clients who are challenged with complying with smoking in designated areas will be educated on the values of following direction, fire safety and accountability. The BHA Manager or designee will conduct daily inspections to ensure all clients are smoking in designated areas and document any concerns. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection conducted on July 22, 2021, the facility failed to ensure that two fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
There was a fire extinguisher, located in the nursing station of the Mansion building, that was last inspected in February of 2020 and a fire extinguisher, located in the Barn building's first floor counselor's office that was missing the fire extinguisher inspection tag, so it was unable to verified when the last inspection was.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Both of these fire extinguishers were inspected and tagged on 7/29/21.
The Plant Operations Manager or designee will inspect all fire extinguishers monthly to ensure they have tags verifying an annual inspection date. |