INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18-20, 2017, by staff from the Division of Drug and Alcohol Program Licensure. 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 inspection:
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
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.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report (SRFSR) during the presubmission process and site licensing review on July 18-20, 2017, the facility failed to ensure one FTE primary care staff person available for every seven clients during primary care hours..
The daily census for 06/03/2017, was 37 patients, requiring a minimum of 6 primary care staff persons, but there were only 5 primary care staff persons working during the following hours:
12:00AM to 7:00AM
3:00PM to 11:00PM.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Our current Detox staff schedule reflects a 1 to 7 staff to client ratio for up to 35 detox clients. The Admissions Director will be notified when our detox census is at 35. Prior to any additional detox admissions, the Admissions Director will notify the DON to ensure we have enough primary care staff available to go above 35 in detox. We will only go above 35 in detox if we have available staff to ensure a 1 to 7 ratio. The Nursing Supervisor will complete a random audit of the detox census vs the staff schedule monthly to ensure that this regulation is being met. The Nursing Supervisor will report her findings to the DON. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of 18 patient records on July 20, 2017, the facility failed to document what information was released to the receiving narcotic treatment program in one of one record reviewed, #17.
Patient #17 was admitted for narcotic treatment on 4/12/2017, and was transferred to a narcotic treatment program on 05/09/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A protocol for transferring patients to an NTP was written. Staff will utilize an NTP transfer sheet to document what information was released to the receiving NTP and once completed will become part of the patient's record. The DON and Nursing Supervisor will train the nurse's via a nursing meeting and email prior to 9/1/17. The DON will complete quarterly chart audits to ensure this regulation is being followed. |