INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 19-20, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, BGI of Brandywine, Inc. 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 investigation.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
The facility failed to hire staff in sufficient numbers to provide consistent monitoring of residents at the facility.
The facility policy states, that ' Tech staff are positioned in various areas throughout the campus to ensure the best overall view of clients possible " , however, a ' Clinical Technician Schedule ' submitted for January, 2020 and February, 2020 indicted that on January 1, 2020 there was only (1) tech listed on the evening shift; additionally, on January 2, 2020 there was only (1) tech listed on the day shift and on January 3, 2020 there were no techs listed on the day shift until 1 pm.
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Plan of Correction
HR has intensified its recruiting practices to include job fairs and online hiring boards. Managers are required to review and make contact with applicable candidates within 24 hours of receipt of application and report back to HR daily. The Clinical Tech Supervisor has retooled his scheduling to assure proper coverage. We can and have pulled staff from other departments to assist when we are short in the Clinical Tech department which did occur on the days in question. Program Director will monitor the Tech staffing on a daily basis to ensure proper coverage. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The facility failed to maintain the Full Time Equivalent ratio of one counselor for every 8 clients.
A Staffing Requirement Facility Summary Report was submitted on February 20, 2020.
*The SRFSR indicated 125 current clients in the non-hospital treatment and rehabilitation activity.
*The SRFSR indicated there are currently 12.2 FTE residential counselors
*This information yields a ratio of (10.24:1) 11:1
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Plan of Correction
As of 3/25/20 we have 15.5 FTE residential counselors. We currently have 117 clients in the non-hospital rehabilitation level of care. We are aware that our current capacity in this level of care is 124 clients to remain within the client to counselor ratios per regulation. The Program Director will continue to monitor client to counselor ratios daily to ensure compliance with the regulation. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to ensure that the facility was maintained and free from danger to health and safety.
A physical plant inspection was conducted on January 19-20, 2020; the following deficiencies were identified:
** broken window blinds in several rooms.
** ceilings in the male rehabilitation unit have tiles which are stained or damaged due to water leaks.
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Plan of Correction
The Plant Operations Manager has begun replacement of all broken window blinds and ceiling tiles to by completed by 3/31/20. Effective 3/12/20 the maintenance department will conduct inspection rounds of all patient areas two times per week and repair any damage. Inspection rounds will be reviewed monthly by the safety committee to ensure compliance. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
The facility failed to ensure that all tubs and showers had slip resistant surfaces.
* No slip resistant mats in the detoxification unit, male wing showers shared by client in bedrooms 49-55.
This is a repeat citation.
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Plan of Correction
The Plant Operations Manager will ensure slip resistant mats are in all bathrooms by 3/31/20. Effective 3/12/20 the maintenance department will conduct inspection rounds of all patient areas two times per week and repair any damage. Inspection rounds will be reviewed monthly by the safety committee to ensure compliance. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The facility failed to ensure that bathrooms were maintained in a functional, clean and sanitary manner.
* Mildew spots on the bathroom ceiling in the male rehabilitation unit.
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Plan of Correction
As of this date, these bathroom ceilings have been cleaned and are free from mildew spots. Effective 3/12/20 the maintenance department will conduct inspection rounds of all patient areas two times per week and ensure all bathrooms are free from mildew. Inspection rounds will be reviewed monthly by the safety committee to ensure compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on interviews with staff and residents, the facility is combining non-residential treatment activities with residential treatment activities, permitting the patients involved in the Partial Hospitalization Program activity to attend residential group therapy though the patients have been admitted to distinct and separate treatment activities.
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Plan of Correction
Effective 3/16/20 we have revised our partial program schedule, including meals and medication times, with staff designated daily to facilitate and monitor these activities to ensure proper separation from the residential programming. The Program Director will review the schedule with the Clinical Director and Clinical Tech Supervisor weekly to ensure compliance. |
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
The facility failed to notify the client of their involuntary discharge in 4 of 8 records reviewed
Client #2 was admitted on 10/14/2019 and was discharged on 10/23/2019.
The discharge notification letter, dated 10/23/2019, has the ' Administrative ' box checked for discharge type, however there is no reason documented for the involuntary discharge.
Client #3 was admitted on 10/4/2019 and was discharged on 10/13/2019.
The discharge summary, dated 10/13/2019, indicates Administrative discharge however, there was no termination letter documented in the record.
Client #5 was admitted on 9/29/2019 and was discharged on 10/5/2019.
Client #5 was listed on the discharged client census as an Administrative discharge on 10/5/2019, however no discharge summary or termination letter were documented in the record.
Client #6 was admitted on 10/7/2019 and was discharged on 10/13/2019.
The discharge summary, dated 10/13/2019, indicates Administrative discharge however, there was no termination letter documented in the record.
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Plan of Correction
Effective 3/15/20 all Nursing and Clinical staff have been re-trained on completion of the "Notice of Involuntary Discharge" form for all administrative discharges. The Medical Records department will review all administrative discharge charts to ensure compliance. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Upon review of incidents submitted by the facility on January 20, 2020, for the period from July, 2019 through February, 2020, the facility failed to report the following incidents to The Department within three business days:
7/17/2019-
Patient inappropriate physical contact with staff
7/31/2019 -
Police called because of a physical altercation between clients
9/28/2019-
911 called, EMT transport of patient
9/29/2019-
Police called for property damage
10/9/2019-
911 was called and EMT transported resident to hospital
10/13/2019-
EMT was called and transported resident to hospital
10/16/2019-
EMT was called and transported resident to hospital
11/10/2019-
911 was called and EMT transported resident to hospital
11/11/2019-
911 was called and EMT transported resident to hospital
11/12/2019-
911 was called and EMT transported resident to hospital
11/13/2019-
911 was called and EMT transported resident to hospital
11/30/2019-
911 was called and EMT transported resident to hospital
12/8/2019-
911 was called for PHP client having medical issues
12/10/2019-
EMT was called and EMT transported resident to hospital
12/13/2019-
EMT was called and EMT transported resident to hospital
12/16/2019-
Police called because of a physical altercation between clients
12/20/2019-
911 was called due to OD; EMT transported resident to hospital
12/28/2019-
EMT was called and EMT transported resident to hospital
2/9/2020-
911 was called due to OD; EMT transported resident to hospital
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Plan of Correction
Effective 3/12/20 the Unusual Incident Policy was reviewed with the Risk Manager who is responsible for reviewing all internal incident reports to identify and complete the Unusual Incident Report for those that need to be submitted to DDAP. The Program Director will review all incident reports on a weekly basis to ensure compliance with this regulation.
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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
The facility failed to provide counseling sessions according to the treatment plan in 4 of 8 records reviewed.
Client #1 was admitted on 12/20/2019 and was discharged on 1/17/2020. The treatment plan, dated 12/20/19, stipulates 1-2 individual session per week.
No individual sessions were documented in this record.
Client #4 was admitted on 10/4/2019 and was discharged on 10/23/2019. The treatment plan, dated 10/4/2019, stipulates 1-2 individual session per week.
No individual sessions were documented in this record.
Client #7 was admitted on 12/18/2019 and was discharged on 1/17/2020. The treatment plan, dated 12/18/2019, stipulates 1-2 individual session per week.
No individual sessions were documented in this record.
Client #8 was admitted on 12/15/2019 and was discharged on 1/18/2020. The treatment plan, dated 12/16/2019, stipulates 1-2 individual session per week.
No individual sessions were documented in this record.
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Plan of Correction
On April 15 during a mandatory meeting the Clinical staff will be re-educated on the importance of documentation of individual sessions as per the treatment plan. Fifteen charts will be reviewed monthly to ensure compliance. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
The facility failed to document a complete client record in 2 of 8 records reviewed
Client #2 was admitted on 10/14/2019 and was discharged on 10/23/2019.
The discharge summary, dated 10/23/2019, had the ' Administrative ' box checked for discharge type, however there is no reason documented for the discharge.
Client #5 was admitted on 9/29/2019 and was discharged on 10/5/2019.
Client #5 was listed on the discharged client census as an Administrative discharge on 10/5/2019, however no discharge summary documented in the record.
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Plan of Correction
On April 15 during a mandatory meeting the Clinical staff will be re-educated on the importance of completing an accurate discharge summary including the reason for discharge. Fifteen charts will be reviewed monthly by the Program Director to ensure compliance. |