INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 29, 2025 through May 1, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure all clinical supervisors participated in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position in one of three applicable personnel records reviewed.
Employee # 4 was hired as a clinical supervisor on November 11, 2024. There was no documentation in the personnel record of monthly meetings with their supervisor during the months of December 2024 and January 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This employee's supervisor was on medical leave during this time. Although his acting supervisor met with him regularly in Dec and Jan, these meetings were not formally documented. BGB protocol will now require all supervisors with planned leave develop an appropriate transition plan for the duration of the planned leave that includes documented supervision meetings with direct reports. HR Dept will monitor compliance with this standard by conducting quarterly audits of supervision notes with findings reported to the RQM Committee. The Director of HR is responsible for implementing this POC. |
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 seventeen applicable personnel records reviewed.
Employee # 18 was hired as a counselor on September 21, 2022. The individual training plan was developed and signed by the employee on March 27, 2025; however, there was no documentation indicating the plan was developed with input from the supervisor.
This is a repeat citation from the May 22, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This employee will meet with their supervisor and review the 3/27/25 Annual Training Plan again and both will sign the plan, bringing it into compliance. HR will conduct quarterly audits of employee files to ensure timely completion of Annual Training Plans and that 100% of plans are signed by both the employee and the supervisor. Audit findings will be reported to the RQM Committee Meeting. The HR Director is responsible for full implementation of this audit. |
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 personnel records, the facility failed to ensure all staff persons received at least 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, within the regulatory time frame in three of eight applicable personnel records reviewed.
Employee # 19 was hired as an intake worker on February 15, 2023. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than February 15, 2025; however, both trainings were not completed as of the date of the inspection.
Employee # 20 was hired as a maintenance worker on July 6, 2022. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than July 6, 2024; however, both trainings were not completed as of the date of the inspection.
Employee # 21 was hired as a driver on March 29, 2023. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than March 29, 2025; however, both trainings were not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 3 employees identified will complete the required trainings by 6/20/25. HR will conduct quarterly audits of employee files to ensure 100% of employees complete required trainings within required timeframes. Audit findings will be reviewed by the RQM Committee. The HR Director and Risk Manager are responsible for full implementation of this POC. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure each clinical supervisor completed at least 12 clock hours of training annually during the facility's January 1, 2024 through December 31, 2024 training year in one of one applicable personnel records reviewed.
Employee # 2 was hired as a clinical supervisor on September 9, 2020. There was 0 training hours documented in the personnel record for the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB has developed an annual mandatory training curriculum for clinical supervisors and will conduct quarterly audits of HR records to ensure 100% of indicated staff have completed mandatory trainings. Audit findings will be reviewed during RQM Committee Meetings. The HR Director and Risk Manager are responsible for implementing and monitoring this POC. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2024 through December 31, 2024 training year in six of six applicable personnel records reviewed.
Employee # 12 was hired as a counselor on September 27, 2023. There were 4 training hours documented in the personnel record for the reviewed training year.
Employee # 13 was hired as a counselor on September 27, 2023. There were 2 training hours documented in the personnel record for the reviewed training year.
Employee # 15 was hired as a counselor on June 16, 2021. There were 5 training hours documented in the personnel record for the reviewed training year.
Employee # 16 was hired as a counselor on August 3, 2022. There were 3 training hours documented in the personnel record for the reviewed training year.
Employee # 17 was hired as a counselor on March 20, 2017. There were 20.5 training hours documented in the personnel record for the reviewed training year.
Employee # 18 was hired as a counselor on September 21, 2022. There were 1 training hours documented in the personnel record for the reviewed training year.
This is a repeat citation from the May 22, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB has developed an annual mandatory training curriculum for counselors and will conduct quarterly audits of HR records to ensure 100% of indicated staff have completed mandatory trainings. Audit findings will be reviewed during RQM Committee Meetings. The HR Director and Risk Manager are responsible for implementing and monitoring this POC. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, the facility failed to have at least 70 square feet of floor space per resident in a single bedroom.
At the time of the inspection on April 30, 2025, at approximately 11:00 AM, Room #7, located in the Mansion building, was a single occupancy bedroom with a single bed, but the room was measured at 56 square feet.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB will no longer designate or assign room #7 in the Mansion as a patient room. BGB will review floor plans to ensure all patient rooms meet the minimum required space per number of assigned patients. Floor plans will identify maximum number of patients per room based on square footage of room. Room assignment compliance will be monitored monthly during RM/Safety Inspections, findings will be reported to the RQM Committee. The Plant Operations Manager and Risk Manager are responsible for implementation of this POC by 6/20/25. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in three of seven applicable personnel records reviewed.
Employee # 13 was hired as a counselor on September 27, 2023. There was no annual performance evaluation documented in the personnel record as of the date of the inspection.
Employee # 15 was hired as a counselor on June 16, 2021. There was no annual performance evaluation documented in the personnel record as of the date of the inspection.
Employee # 16 was hired as a counselor on August 3, 2022. There was no annual performance evaluation documented in the personnel record 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
The Clinical Supervisor will meet with indicated staff and complete annual performance evaluations by 6/13/25. HR will conduct quarterly audits on employee records to ensure 100% of staff have appropriately completed performance evaluations, findings will be reported to and reviewed by RQM Committee. The HR Director and Risk Manager are responsible for implementation and monitoring of 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 fourteen applicable client records reviewed.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on March 17, 2025 and was discharged on March 22, 2025. In the record, there was a release of information form to an employer, signed by the client on March 17, 2025. The release form indicated the purpose of the disclosure was "other"; however, there was no additional explanation of what the "other" purpose was.
Client # 10 was admitted to the inpatient non-hospital activity on March 22, 2025 and was still active at the time of the inspection. In the record, there was a release of information form to an employer, signed by the client on March 17, 2025. The release form indicated the purpose of the disclosure was "other"; however, there was no additional explanation of what the "other" purpose was.
Client # 11 was admitted to the inpatient non-hospital activity on September 26, 2024 and discharged on October 21, 2024. In the record, there was a release of information form, signed by the client on October 16, 2024. The release form indicated the purpose of the disclosure was "other"; however, there was no additional explanation of what the "other" purpose was.
Client # 12 was admitted to the inpatient non-hospital activity on November 20, 2024 and discharged on January 29, 2025. In the record, there were several release of information forms to an emergency contact, a government agency, and other treatment providers and sober living facilities, signed by the client on December 14, 2024, December 17, 2024, December 30, 2024, January 2, 2025, January 3, 2025, January 4, 2025, January 17, 2025 or January 27, 2025. Every release form indicated the purpose of the disclosure was "other"; however, there was no additional explanation of what the "other" purposes were.
Client # 13 was admitted to the inpatient non-hospital activity on February 16, 2025 and discharged on March 7, 2025. In the record, there was a release of information form to another treatment provider, signed by the client on March 6, 2025. The release form indicated the purpose of the disclosure was "other"; however, there was no additional explanation of what the "other" purpose was.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The indicated ROIs will be revoked in each chart. Staff received training on 5/15/25 and 5/21/25 regarding appropriate completion of Consent forms and the use of 'other' as a purpose of release. Staff have been trained on how to appropriately document/describe 'other' when used as a purpose of release. BGB will randomly audit no less than 5 patient charts monthly to ensure compliance with this standard, findings will be reported to RQM Committee. The Risk Manager and Clinical Director are responsible for implementation of this audit. |
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 records reviewed.
Client # 15 was admitted to the inpatient non-hospital activity on February 8, 2025 and was administratively discharged on February 28, 2025. There was no documentation, in the record, indicating the client was given written notification 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 training on 5/15/25 and 5/21/25 on regulatory requirements for completion of Notice of Involuntary Termination of Treatment forms for every client who is administratively discharged. BGB will conduct monthly audits of a random sampling of no less than 5 charts to ensure compliance with this standard, findings will be reported to and reviewed by RQM Committee. The Clinical Director and Risk Manager are responsible for the 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 unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
There were incidents on June 26, 2024, July 23, 2024, and October 28, 2024 which required police or ambulance personnel to be at the facility; however, there was no documentation that these three unusual incidents were reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BGB will conduct regular reconciliation of patient incident reports to ensure timely notification to DDAP of the presence of police, fire or ambulance on site. Timeliness of incident reporting is reviewed daily by the leadership team. The Risk Manager is responsible for implementation of this POC. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, which is to include their name, address, date of birth, emergency contact, and other identifying data, prior to the administration of an agent in seven of eleven applicable patient records reviewed.
Patient # 1 was admitted to the inpatient non-hospital detoxification activity on April 23, 2025 and was still active at the time of the inspection. There was no documentation, in the record, of the client identifying their emergency contact prior to the administration of an agent.
Patient # 3 was admitted to the inpatient non-hospital detoxification activity on March 29, 2025 and was discharged on April 3, 2025. There was no documentation, in the record, of how the patient's identity was verified.
Patient #6 was admitted to the inpatient non-hospital detoxification activity on November 16, 2024 and was discharged on November 20, 2024. There was no documentation, in the record, of how the patient's identity was verified.
Patient # 7 was admitted to the inpatient non-hospital detoxification activity on February 16, 2025 and was discharged on March 7, 2025. There was no documentation, in the record, of how the patient's identity was verified.
Patient # 12 was admitted to the inpatient non-hospital activity on November 20, 2024 and discharged on January 29, 2025. There was no documentation, in the record, of how the patient's identity was verified.
Patient # 13 was admitted to the inpatient non-hospital activity on February 16, 2025 and discharged on March 7, 2025. There was no documentation, in the record, of how the patient's identity was verified.
Patient # 14 was admitted to the inpatient non-hospital activity on April 3, 2025 and discharged on April 3, 2025. There was no documentation, in the record, of how the patient's identity was verified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
BGB will develop a protocol for the appropriate verification of patient identity. All indicated staff will receive training on the protocol by 6/30/25. Training documentation will be maintained by HR in the individual employee record. BGB will conduct monthly audits of intake and admission records to ensure the record contains documentation of verification of identity, findings will be reported to and reviewed by the RQM Committee. The Director of Admissions and Risk Manager are responsible for implementation and monitoring of this POC. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to ensure patient records, including the medical and psychosocial summaries and urinalysis reports or summary, were transferred to the receiving narcotic treatment program in one of one applicable patient record reviewed.
Patient # 12 was admitted to the inpatient non-hospital activity on November 20, 2024 and was transferred to another treatment provider on January 29, 2025. There was no documentation indicating the medical and psychosocial summaries and urinalysis reports/summary were transferred to the receiving narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been trained regarding the requirement of appropriate transmission of psychosocial summaries and urinalysis reports to receiving the NTP. 100% of patients transferring to a new NTP provider post discharge from BGB will have documentation of transmission of indicated information to the receiving NTP. BGB will conduct random audits of no less than 5 charts per month to ensure compliance with this standard, findings will be reported to and reviewed by the RQM Committee. The Risk Manager and DON are responsible for implementation of this POC. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in two of two applicable patient records reviewed.
Patient # 1 was transferred in and admitted to the inpatient non-hospital detoxification activity on April 23, 2025 and was still active at the time of inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 6 was transferred in and admitted to the inpatient non-hospital detoxification activity on July 25, 2024 and was discharged on November 7, 2024. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given at the time of admission. At the time of the client's discharge the facility documented that they notified the narcotic treatment program of the date of admission and the date the initial dose was given via a transfer form; however, the facility policy and procedure manual states that the notification will be documented in a progress note.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff have been trained regarding the requirement of appropriate notification to the referring NTP of an applicable patient's admission date and date of initial dosing. 100% of applicable patients records will contain documentation of required notification to the referring NTP. BGB will conduct random audits of no less than 5 charts per month to ensure compliance with this standard, findings will be reported to and reviewed by the RQM Committee. The Risk Manager and DON are responsible for implementation of this POC. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure counseling services were being provided to the client according to the individual treatment and rehabilitation plan in three of six applicable client records reviewed.
Client # 10 was admitted to the inpatient non-hospital activity on March 22, 2025 and was still active at the time of the inspection. The individual treatment plan, completed on March 21, 2025, and subsequent treatment plan updates, completed on March 27, 2025, April 19, 2025 and April 27, 2025, indicated the client was to receive one individual therapy session per week. The only individual therapy sessions documented in the client's record of service and progress notes were conducted on March 21, 2025, April 19, 2025 and April 27, 2025.
Client # 11 was admitted to the inpatient non-hospital activity on September 26, 2024 and discharged on October 21, 2024. The individual treatment plan, completed on September 29, 2024, and subsequent treatment plan updates, completed on October 8, 2024, October 20, 2024 and October 21, 2024, indicated the client was to receive one individual therapy session per week. There was no individual therapy sessions documented on the client's record of service and progress notes during the week of October 13, 2024 through October 19, 2024.
Client # 12 was admitted to the inpatient non-hospital activity on November 20, 2024 and discharged on January 29, 2025. The individual treatment plan, completed on November 22, 2024, and subsequent treatment plan updates, completed on December 30, 2024, January 6, 2025 and January 13, 2025, indicated the client was to receive one individual therapy session per week. There was no individual therapy sessions documented on the client's record of service and progress notes during the weeks of December 8, 2024 through December 28, 2024 and January 12, 2025 through January 18, 2025.
This is a repeat citation from the May 22, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff were trained on 5/15/25 and 5/21/25 regarding review of treatment plans to ensure counseling services are provided according to individual treatment plans. 100% of clients will have documentation of counseling services as outlined in the individual treatment plan, or progress notes documenting the reason a service was not provided. BGB will conduct a random audit of no less than 5 charts monthly to ensure compliance with this standard, findings will be reported to RQM Committee. The Clinical Director and Risk Manager are responsible for implementation of this POC. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 maintain a complete client record on an individual, which is to include documentation of follow-up information, in one of three applicable client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on September 26, 2024 and discharged on October 21, 2024. There was no follow-up information in the record at the time of inspection.
This is a repeat citation from the June 9, 2023, December 12, 2023, and May 22, 2024, licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BGB will ensure 100% of discharged patient's will have documentation of attempts by BGB to contact patient for follow up within 14 days post-discharge. BGB maintains a log of all attempts and/or successful follow up activity. BGB will conduct random audits of no less than 5 charts per month to ensure compliance with this standard, findings will be reported to and reviewed by the RQM Committee. The Risk Manager is responsible for implementation of this POC. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for documenting follow-up information in the client record was submitted and approved by the Department for the June 9, 2023 and May 22, 2024 annual licensing renewal inspections and the December 12, 2023 provisional license follow-up inspection. Not documenting follow-up information in the record was again found to be a deficiency in the April 29, 2025 through May 1, 2025 annual licensing inspection.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
BGB has designated staff to make all follow-up contacts. BGB maintains a log of all attempted and/or successful follow up activity. BGB will conduct random audits of no less than 5 charts per month to ensure compliance with this standard, findings will be reported to and reviewed by the RQM Committee. Additionally, BGB has developed and implemented a POC tracker that is reviewed by the Leadership team twice monthly, and the RQM Committee monthly, to ensure consistent monitoring of POC activity and progress to/from stated objectives. Initial RQM Committee review of the POC tracker occurred on 6/10/25. The Risk Manager is responsible for the implementation of this POC. |