INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2025 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 LLC 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 personnel records, the facility failed to ensure an annual, written individual training plan was developed for each employee, with input from both the employee and the supervisor in one of three applicable personnel records reviewed.
Employee # 2 was hired as a clinical supervisor on May 16, 2016. The individual training plan was developed and signed by the employee on March 21, 2025; however, there was no documentation indicating the plan was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Annual plan for employee #2 was reviewed again with employee and supervisor and re-signed by both. HR to conduct regular QA monitoring of training plans. |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the partial hospitalization program had a minimum of one Full Time Equivalent (FTE) counselor who provides direct counseling services to every ten clients.
The counselor FTE is determined by dividing the total number of hours counselors devote to their clients by the facility's workweek. Then, in order to obtain the ratio, the total number of partial hospitalization clients the facility serves is divided by the FTE.
As of April 25, 2025, the facility employed two clinical staff who dedicated a total of 70 hours to the 24 active partial hospitalization clients within a 40-hour workweek. Therefore, the facility's ratio calculation was as follows: 70/40 = 1.75(FTE); 24/1.75 = 13.7142, which equals to a client/counselor FTE ratio of 13:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB is restructuring the PHP program to include hiring a new clinical supervisor for the PHP program, bringing the total number of counselors to 3. This new clinical supervisor will carry a caseload of no less than 4 clients at any given time as well as provide supervisory oversight. The Director of Clinical Services is responsible for ensuring the full implementation of this POC. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's June 2024 through March 2025 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
At the time of the inspection, there was no documentation indicating a fire drill was conducted for the month of June 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB has developed an emergency drill schedule that specifies a monthly drill to occur on different shifts and days of the week each month. Completion of emergency drills in accordance with the schedule will be reviewed during BGB's monthly Safety Committee meeting. The Risk Manager and Facility Maintenance Manager are responsible for full implementation of this POC. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's June 2024 through March 2025 fire drill logs, the facility failed to conduct fire drills on different days of the week and at different times of the day.
The fire drill log indicated that all fire drills conducted were completed during the weekdays and between 9:53am and 11:03am. The facility ' s hours of operation are reported as seven days a week from 8am to 5pm. There were no weekend or afternoon fire drills conducted during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB has developed an emergency drill schedule that specifies different shifts and days of the week for each drill. Completion of emergency drills in accordance with the schedule is reviewed during BGB's monthly Safety Committee meeting. The Risk Manager and Facility Maintenance Manager are responsible for fully implementing this POC. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in five of seven client records reviewed.
Client # 1 was admitted on January 17, 2025 and was still active at the time of the inspection. The record included several release of information forms to other treatment providers and sober living facilities, signed by the client on January 17, 2025, January 24, 2025, February 4, 2025, February 5, 2025, February 13, 2025, March 5, 2025, or April 24, 2025. Each form indicated that the purpose of the disclosure was "other" and was to be specified; however, none of the forms included documentation of what the "other" purposes were.
Client # 2 was admitted on January 4, 2025 and was still active at the time of the inspection. The client record contained several release of information forms to public defenders, other treatment providers and sober living facilities, signed by the client on January 14, 2025, January 24, 2025, February 6, 2025, February 25, 2025, March 19, 2025, or April 18, 2025. Each form indicated that the purpose of the disclosure was "other" and was to be specified; however, none of the forms included documentation of what the "other" purposes were.
Client # 3 was admitted on March 17, 2025 and was still active at the time of the inspection. The client record contained a release of information form to another treatment provider, signed by the client on February 10, 2025. The form indicated that the purpose of the disclosure was "other" and was to be specified; however, the form did not include documentation of what the "other" purposes were.
Client # 5 was admitted on December 27, 2025 and was discharged on February 13, 2025. The client record contained several release of information forms to other treatment providers and sober living facilities, signed by the client on January 2, 2025, January 6, 2024, January 14, 2025, or January 24, 2025. Each form indicated that the purpose of the disclosure was "other" and was to be specified; however, none of the forms included documentation of what the "other" purposes were.
Client # 6 was admitted on July 25, 2024 and was discharged on November 7, 2024. The client record contained a release of information form to another treatment provider, signed by the client on October 2, 2024. The form indicated that the purpose of the disclosure was "other" and was to be specified; however, the form did not include documentation of what the "other" purposes were.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
BGB clinical staff received refresher training on 5/15/25 and 5/21/25 regarding HIPAA Privacy Rule requirements and how to appropriately complete the Authorization to Release Information Forms, specifically how to include a description when using 'other' as a purpose for the release of information. BGB will meet with those identified clients who are still active in the program and have new ROIs completed in a manner compliant with this standard. For client's who have discharged at the time of this POC, the consents identified will be revoked. A random sampling of no less than 5 patient records will be audited monthly to ensure ongoing compliance with this standard, audit findings will be reported to the RQM Committee monthly meeting. The Clinical Director and Risk Manager are responsible for fully implementing this POC |
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 notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client record reviewed.
Client #4 was admitted on September 14, 2024 and was administratively discharged on October 5, 2024. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB clinical staff received refresher training on 5/15/25 and 5/21/25 relating to appropriate completion of mandatory documentation when a patient is administratively discharged. Clinical staff understand that a Notice of Involuntary Termination of Treatment must be completed, and a copy offered, for each client who is administratively discharged. An audit of all ADM client charts will be conducted monthly with findings reported to RQM Committee the following month. The Risk Manager and Clinical Director are responsible for full implementation of this POC. |
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 the facility's June 2024 through April 2025 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident that required the presence of police and/or ambulance personnel at the facility.
On August 10, 2024, there was an incident at the facility that required the presence of police and/or ambulance personnel. The incident was not reported to the Department until August 20, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB has maintained 100% compliance with unusual incident reporting to the Department since 9/2024. BGB monitors compliance with incident reporting to all sources on a daily basis and reviews KPIs during Leadership Team Mtgs. The Risk Manager is responsible for full implementation of this POC. |
709.82(a)(1) 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short and long-term goals for treatment as formulated by both staff and client on the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client # 1 was admitted on January 17, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on January 18, 2025 did not include the documentation of any long-term goals.
Client # 2 was admitted on January 4, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, completed on January 18, 2025 did not include the documentation of any long-term goals.
Client # 5 was admitted on December 27, 2025 and was discharged on February 13, 2025. The individual treatment and rehabilitation plan, completed on December 28, 2024 did not include the documentation of any long-term goals.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BGB clinical staff received refresher training on 5/21/25 regarding appropriate treatment planning, including establishing long vs short term goals. For those treatment plans identified for clients who are still active in the program, the counselor will meet with them to update the treatment plan to include measurable long and short term goals. Moving forward, all treatment plans will include measurable long term and short term goals. A random sampling of no less than 5 charts will be conducted monthly to ensure compliance with this standard, with audit findings reported to the RQM Committee at the monthly meeting following the audit. The Risk Manager and Clinical Director are responsible for full implementation of this POC. |
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 client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of seven client records reviewed.
In every client record reviewed, the client's individual treatment and rehabilitation plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB clinical staff received refresher training on 5/21/25 regarding appropriate treatment planning, including identifying the type of frequency of treatment and rehabilitation services in the treatment plan. For treatment plans identified during the survey, for clients who are still active in the program, the counselor will meet with the client to update the treatment plan to include documentation of the type and frequency of services by 6/5/2025. Moving forward, all treatment plans will identify the type and frequency of services. A random sampling of no less than 5 charts will be conducted monthly to ensure compliance with this standard, with audit findings reported to the RQM Committee at the monthly meeting following the audit. The Risk Manager and Clinical Director are responsible for full implementation of this POC. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in seven of seven client records reviewed.
In every client record reviewed, the client's individual treatment and rehabilitation plan did not include the documentation of any proposed types of support services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB clinical staff received refresher training on 5/21/25 regarding appropriate treatment planning, including identification and documentation of proposed support services during and post discharge. For the identified charts that are still active, the counselor will meet with the client to update the treatment plan to identify specific proposed support services, by 6/5/2025. Moving forward, all treatment plans will include identified proposed support services. A random sampling of no less than 5 charts will be conducted monthly to ensure compliance with this standard, with audit findings reported to the RQM Committee at the monthly meeting following the audit. The Risk Manager and Clinical Director are responsible for full implementation of this POC. |
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 ensure all treatment and rehabilitation plans were reviewed and updated at least every 30 days in two of six client records reviewed.
Client # 3 was admitted on March 17, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 19, 2025 and an update was due no later than April 19, 2025; however, the update was not completed until April 24, 2025.
Client # 6 was admitted on July 25, 2024 and was discharged on November 7, 2024. A treatment plan update was completed on September 24, 2024 and the next update was due no later than October 24, 2024; however, the update was not completed until October 30, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BGB clinical staff received refresher training on 5/21/25 regarding appropriate treatment planning, including ensuring compliance with regulatory requirements relating to timely review and updates of treatment plans. A random sampling of no less than 5 charts will be conducted monthly to ensure compliance with this standard, with audit findings reported to the RQM Committee at the monthly meeting following the audit. The Clinical Director and Risk Manager are responsible for full implementation of this POC |
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 maintain a complete client record, which is to include the documentation of case consultation notes, in two of three applicable client records reviewed.
Client # 1 was admitted on January 17, 2025 and was still active at the time of the inspection. There was no documentation of case consultation notes in the record at the time of the inspection.
Client # 3 was admitted on March 17, 2025 and was still active at the time of the inspection. There was no documentation of case consultation notes in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff received refresher training on 5/21/25 regarding appropriate treatment planning, including regulatory requirements pertaining to case consultations and documentation thereof. For the charts identified for clients who are still active, the counselor will facilitate and document a case consultation by 6/5/25. Moving forward, all clients will have a documented timely case consultation. A random sampling of no less than 5 charts will be conducted monthly to ensure compliance with this standard, with audit findings reported to the RQM Committee at the monthly meeting following the audit. The Risk Manager and Clinical Director are responsible for full implementation of this POC. |