INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 17, 2017 by staff from the Division Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, BGI of Brandywine, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
A physical plant inspection was conducted on May 17, 2017. Based on this inspection, the facility failed to be free from rodent infestation as there was rodent excrement observed in the dining area and the kitchen pantry of the Main Building. In addition, rodent excrement was observed in a client bedroom on the second floor of the Mansion.
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Plan of Correction
Ehrlich, a pest control company, initially placed rodent stations in strategic locations around the affected buildings (Motel and Mansion) on 5/8. On 5/22 during a follow up visit, rodent activity was noted in the stations and bait replaced. On 5/24 more bait stations were added due to continued activity. On 6/12, Ehrlich found no activity in several interior bait stations. They did replace bait in a few external stations. Ehrlich will continue to monitor every 2 weeks. In addition, on 5/22 we added an announcement to our daily resident community meeting regarding no food in the rooms and our tech staff has been more assertive in removing food from the resident rooms during daily room inspections. All of these efforts appear to be working as we haven't heard of a mice complaint in several weeks. The tech supervisor will continue to monitor that staff are removing food from resident rooms daily during inspection by performing a spot check weekly. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
A review of client files was conducted on May 17, 2017. Based on this review, the facility failed to provide counseling to clients on a regular and scheduled basis.
Client #1 was admitted April 28, 2017. The treatment plan, dated May 04, 2017 indicated that individual counseling was provided "as needed."
Client #2 was admitted May 06, 2017. The treatment plan May 06, 2017 indicated that individual counseling was provided "as needed."
In an interview with facility staff it was indicated that individual sessions are to be conducted once a week and not "as needed".
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Plan of Correction
On 5/23 the Clinical Supervisors conducted a training regarding the "as needed" language for individual counseling. The expectation is that treatment plans reflect individual counseling a minimum of 1x/week. This will be monitored during weekly chart audits conducted by the Clinical Supervisors. |