INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 13-14, 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client in 3 of 3 applicable records reviewed.
Client # 1 was admitted on June 29, 2024, and administratively discharged on July 2, 2024. A Notice of Involuntary Discharge was in the client record; however, this notice was not signed by the client and there was no documentation in the record that the client received this notice.
Client # 4 was admitted on May 12, 2024, and administratively discharged on June 2, 2024. A Notice of Involuntary Discharge was in the client record; however, this notice was not signed by the client and there was no documentation in the record that the client received this notice.
Client # 6 was admitted on June 18, 2024, and administratively discharged on July 5, 2024. A Notice of Involuntary Discharge was in the client record; however, this notice was not signed by the client and there was no documentation in the record that the client received this notice.
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Plan of Correction
Reviewed all client records and issued required written notifications to affected clients.
The Compliance manager and Clinical Director will provide immediate refresher training to staff on the proper procedure for issuing written termination notices by 9/27/2024
Systemic Corrections:
Compliance Manager will Updated policies and procedures to align with § 709.33(a) and created a standardized termination notice template.
Implemented a tracking system and checklist for documenting written termination notices by 9/27/2024
Staff Training: The Clinical Director will conduct mandatory training on updated policies and the importance of compliance with § 709.33(a).
Established ongoing training and education programs By 9/27/2024
Monitoring and Evaluation:
The Compliance Manager and Referral Coordinator will conduct introduced monthly audits of termination notices to ensure compliance.
Created a feedback mechanism for clients to report issue by 9/27/2024
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to document the client had an opportunity to request reconsideration of a decision terminating treatment.
Client # 1 was admitted on June 29, 2024, and administratively discharged on July 2, 2024. A Notice of Involuntary Discharge was in the client record; however, this notice was not signed by the client. There was no documentation that the client had an opportunity to request reconsideration of the decision to terminate treatment.
Client # 4 was admitted on May 12, 2024, and administratively discharged on June 2, 2024. A Notice of Involuntary Discharge was in the client record; however, this notice was not signed by the client. There was no documentation that the client had an opportunity to request reconsideration of the decision to terminate treatment.
Client # 6 was admitted on June 18, 2024, and administratively discharged on July 5, 2024. A Notice of Involuntary Discharge was in the client record; however, this notice was not signed by the client. There was no documentation that the client had an opportunity to request reconsideration of the decision to terminate treatment.
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Plan of Correction
Document Review and Update: The Risk Manager and Clinical Director reviewed records of client issued updated Notices of Involuntary Discharge, and documented the clients' opportunities to request reconsideration by 9/27/2024
Client Notification: The Risk Manager ensured that clients received the updated notices and had the opportunity to request reconsideration by 9/27/2024
Systemic Corrections:
Policy Update: The Risk Manager and Clinical Director revised the facility's policies and procedures to include requirements for documenting reconsideration opportunities and obtaining client signatures on discharge notices before 9/27/2024
Documentation Protocol: Implemented a standardized protocol with a checklist to verify compliance with documentation requirements before finalizing discharge decisions by 9/27/2024
Staff Training and Education:
Training Sessions: The Risk Manager and Clinical Director conducted training for staff on the updated procedures for documenting discharge decisions and reconsideration opportunities by 9/27/2024
Ongoing Education: Established a schedule for ongoing training and created educational resources for staff by 9/27/204
Monitoring and Evaluation
Regular Audits: The Risk Manager initiated regular audits of client records to ensure compliance with documentation requirements by 9/27/2024
Compliance Tracking: Developed a tracking system to monitor the completion and accuracy of discharge documentation by 9/27/2024 |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documentation, the facility failed to file a written unusual incident report with the Department within 3 business days of an incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
It was discovered that the facility had unusual incidents that occured on August 2, 2024, August 4, 2024, August 5, 2024, August 7, 2024, and August 8, 2024, all of which involved police or ambulance personnel onsite and the facility did not submit an unusual incident report to the Department.
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Plan of Correction
Report Submission: The Risk Manager immediately filed the required unusual incident report with DDAP.
Incident Review: The Risk Manager reviewed the incident to ensure all necessary details were included in the report.
Systemic Corrections:
Policy Update: The Risk Manager updated the facility's policies and procedures for reporting unusual incidents to ensure compliance with the 3-business-day requirement.
Reporting System:The Risk Manager implemented a new tracking system with automated reminders for timely report submissions before 9/27/2024
Staff Training and Communication:
Training: The Risk Manager conducted training for staff on the updated reporting procedures and the importance of timely submission 9/27/2024
Communication: Distributed new guidelines to all relevant staff to reinforce reporting requirements by 9/27/2024
Monitoring and Evaluation:
Audits: The Risk Manager initiated regular internal audits to verify compliance with reporting procedures and addressed any issues identified bu 9/27/24
Compliance Tracking: Created a compliance dashboard to track unusual incident report submissions and ensure deadlines are met by 9/27/2024 |
709.4(b) LICENSURE Subchapter A.General Provisions.Exceptions
709.4. Exceptions.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
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Observations
Based on a review of the client census on August 13, 2024, and the current approved requests for exceptions, the facility failed to submit a written request to extend an exception to regulation 705.5 for sleeping accommodations.
The approved client capacity for inpatient residential services is 135. On August 13, 2024, the client census for inpatient residential services was 143. The last request to flex beds between the detoxification service and the inpatient residential service expired on September 30, 2021.
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Plan of Correction
Extension Request: The CEO immediately prepared and submitted the necessary written request for an extension of the flex bed exception.
Capacity Review: The Admission Supervisor will adjust client placements to comply with the approved capacity while awaiting the extension approval effective immediately
Systemic Corrections:
Policy Update: The Risk Manager reviewed and updated policies and procedures related to flex bed requests and compliance with regulation 705.5. New protocols for timely submissions were established effective immediately
Leadership Transition Protocol: Implemented a transition protocol to ensure compliance tasks are managed effectively during leadership changes.
Staff Training and Communication:
Training: Risk Manager Conducted training for staff on updated procedures related to flex bed requests and capacity regulations.
Communication Plan: Developed and executed a communication plan to ensure adherence to new procedures by 9/7/2024
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