INITIAL COMMENTS
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This report is a result of an on-site unusual incident investigation conducted on January 5, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site unusual incident investigation, BGI of Brandywine, INC was found to not 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on an onsite visit to the facility on January 5, 2023, the facility failed to not permit in the facility heaters that are not permanently mounted or installed.
There was a space heater on in the facility director ' s office at the time of the onsite visit.
This finding was reviewed with facility staff during the investigation process.
This is a repeat citation from the July 19, 2022 - July 20, 2022 licensing inspection.
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Plan of Correction
The Plant Operations Manager or
designee will conduct weekly rounds
of the facility grounds and buildings
and address any concerns within a
reasonable timeframe. The Program
Director removed space heater and will conduct monthly rounds to ensure ongoing
compliance with this regulation.
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of one client record, the facility failed to obtain and informed and voluntary consent from the client for the disclosure of information contained in the client record that included specific information disclosed.
Client #1 was admitted on December 9, 2022. An informed and voluntary consent for a pharmacy was signed and dated by the client on December 9, 2022, but the specific information to be disclosed was missing. A fax confirmation sheet dated December 9, 2022, confirmed information was disclosed.
This finding was reviewed with facility staff during the investigation process.
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Plan of Correction
Staff will be reeducated on proper consent documentation. Staff will be reeducated that a consent is not considered valid unless all information is completed on the consent.
Education will be provided by clinical director and nursing director via staff meetings and emails.
A spreadsheet for reconciliation of consents is reviewed daily and updated.
Completion date 4-14-23 |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of one client record, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment.
Client #1 was admitted on December 9, 2022. There was a document in the record that provided the required information of the informed consent, however there was not a patient signature to provide written consent. There was documentation that the physician ordered 50 mg of methadone for the patient on December 9, 2022.
This finding was reviewed with facility staff during the investigation process.
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Plan of Correction
Staff will be reeducated on proper consent documentation. Staff will be reeducated that a consent is not considered valid unless all information is completed on the consent.
Education will be provided by clinical director and nursing director via staff meetings and emails.
A spreadsheet for reconciliation of consents is reviewed daily and updated.
Completion date 4-14-23 |