INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 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 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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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 September 2020 through May 2021 fire drill log, the facility failed to ensure that unannounced fire drills were conducted at least once a month for the months of October 2020, December 2020, and February 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Supervisor will maintain a yearly schedule of fire drills to be conducted monthly. All fire drill documentation will be reviewed at the monthly safety committee meetings to ensure compliance. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #6 was admitted on April 28, 2021 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards related to completing a consent to release information prior to disclosure during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor to verify that all consents to release information have been completed accurately and timely. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which a consent form would expire in one of seven client records reviewed.
Client #3 was admitted on February 16, 2021 and was discharged on March 16, 2021. The release of information form to an outside provider was signed and dated by the client on March 9, 2021, but the release form failed to document the expiration date, event, or condition.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards related to accurate completion of a consent to release information including expiration dates/conditions during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor to verify that all consents to release information have been completed accurately and timely. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document, during the intake process, the drug and alcohol history of a client in three of seven client records reviewed.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. There was no documentation in the client record of the client ' s drug and alcohol history at the time of the inspection.
Client #5 was admitted on May 13, 2021 and was still active at the time of the inspection. There was no documentation in the client record of the client ' s drug and alcohol history at the time of the inspection.
Client #7 was admitted on May 25, 2021 and was still active at the time of the inspection. There was no documentation in the client record of the client ' s drug and alcohol history at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of a drug and alcohol history during the intake process during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor(s) to verify that clinical documentation includes a drug and alcohol history during intake. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document, during the intake process, the personal history of a client in three of seven client records reviewed.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. There was no documentation in the client record of the client ' s personal history at the time of the inspection.
Client #5 was admitted on May 13, 2021 and was still active at the time of the inspection. There was no documentation in the client record of the client ' s personal history at the time of the inspection.
Client #7 was admitted on May 25, 2021 and was still active at the time of the inspection. There was no documentation in the client record of the client ' s personal history at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of a personal history during the intake process during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor(s) to verify that clinical documentation includes a personal history during intake. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, during the intake process, the psychosocial evaluation of a client in four of seven client records reviewed.
Client #1 was admitted on November 30, 2020 and was discharged on December 26, 2020. There was no documentation in the client record of the psychosocial evaluation at the time of the inspection.
Client #2 was admitted on December 14, 2020 and was discharged on February 9, 2021. There was no documentation in the client record of the psychosocial evaluation at the time of the inspection.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. There was no documentation in the client record of the psychosocial evaluation at the time of the inspection.
Client #7 was admitted on May 25, 2021 and was still active at the time of the inspection. There was no documentation in the client record of the psychosocial evaluation at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of a psychosocial evaluation during the intake process during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor(s) to verify that clinical documentation includes a psychosocial evaluation. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
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 provide treatment plan updates within the regulatory timeframe in two of two applicable client records reviewed.
Client #2 was admitted on December 14, 2020 and was discharged on February 9, 2021. The comprehensive treatment plan was completed on December 17, 2020 and an update was due no later than January 17, 2021. However, the update was not completed prior to discharge.
Client #6 was admitted on April 28, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was completed on April 28, 2021 and an update was due no later than May 28, 20210. However, the update was not completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of a treatment plan update every 30 days during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor(s) to verify that clinical documentation includes a treatment plan update every 30 days as applicable. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that clients received counseling on a regular and scheduled basis, in particular providing individual counseling sessions at least twice weekly in five of seven client records reviewed.
Client #1 was admitted on November 30, 2020 and was discharged on December 26, 2020. The record's progress notes indicated that the client had received a total of two individual counseling sessions during the entire treatment episode - December 1, 2020 and December 9, 2020.
Client #2 was admitted on December 14, 2020 and was discharged on February 9, 2020. The record's progress notes indicated that the client had received a total of three individual counseling sessions during the entire treatment episode - December 17, 2020, December 24, 2020, and December 30, 2020.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. There were no progress notes documented in the record at the time of the inspection, which indicated that the client did not receive any individual counseling sessions during the entire treatment episode.
Client #5 was admitted on May 13, 2021 and was still active at the time of the inspection. The record's progress notes and record of services indicated that the client had received a total of three individual counseling sessions during the treatment episode as of the date of the inspection - May 15, 2021, May 19,2021, and May 28, 2021.
Client #6 was admitted on April 28, 2021 and was still active at the time of the inspection. The record's progress notes and record of services indicated that the client had received a total of six individual counseling sessions during the treatment episode as of the date of the inspection - May 3, 2021, May 6, 2021, May 10, 2021, May 12, 2021, May 20, 2021, and May 25, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of an individual session at least twice weekly during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor(s) to verify that clinical documentation includes individual sessions two times per week. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
709.83(a)(8) 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:
(8) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a record of services, in three of seven client records reviewed.
Client #1 was admitted on November 30, 2020 and was discharged on December 26, 2020. The client record did not document a record of services at the time of the inspection.
Client #2 was admitted on December 14, 2020 and was discharged on February 9, 2021. The client record did not document a record of services at the time of the inspection.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. The client record did not document a record of services at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of a record of service during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor(s) to verify that clinical documentation includes a record of service. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a discharge summary, in three of four applicable client records reviewed.
Client #1 was admitted on November 30, 2020 and was discharged on December 26, 2020. The client record did not document a discharge summary at the time of the inspection.
Client #2 was admitted on December 14, 2020 and was discharged on February 9, 2021. The client record did not document a discharge summary at the time of the inspection.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. The client record did not document a discharge summary at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of a discharge summary during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Medical Records department to verify that clinical documentation includes a discharge summary in the client record. Results of these chart audits will be reported to the Clinical Director and Clinical Supervisors will share these results with the staff during monthly supervision. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in three of four applicable client records reviewed.
Client #1 was admitted on November 30, 2020 and was discharged on December 26, 2020. The client record did not document any follow-up information at the time of the inspection.
Client #2 was admitted on December 14, 2020 and was discharged on February 9, 2021. The client record did not document any follow-up information at the time of the inspection.
Client #4 was admitted on April 20, 2021 and was discharged on May 18, 2021. The client record did not document any follow-up information at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the standards regarding documentation of follow up information during staff meetings on 6/3/21 and 7/3/21. Staff will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Medical Records to verify documentation of follow up information in the client record. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |