INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 14, 2025, by staff from the Bureau of Program Licensure. 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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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 administrative documentation, the facility failed to inform the Department of an unusual incident with the required three days.
It was discovered that the police were onsite on 4/2/25, and the facility did not submit a written unusual incident report to the Department within the regulatory timeframe.
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Plan of Correction
Report#1099007 submitted on 6/9/25 relating to this incident. Staff received refresher training relating to reportable incidents on 5/15/25 and 5/21/25. BGB will continue to monitor timely submission of incident reports to DDAP to ensure 100% compliance with this standard. The Risk Manager is responsible for implementation of this corrective action. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one of one applicable record reviewed.
Client # 5 was admitted 4/7/25 and discharged 5/5/25. The client record did not contain documentation of an aftercare plan.
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Plan of Correction
Staff received refresher training on 5/15/25 and 5/21/25 relating to standards for after/discharge planning documentation. BGB will audit a random sampling of no less than 5 charts monthly to ensure compliance with this standard, findings will be reported to the monthly RQM Committee Mtg. The Risk Manager and Clinical Director are responsible for the implementation of this POC. |
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
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in 4 of six records reviewed.
Client # 2 was admitted on 3/11/25 and discharged on 3/27/25. The client record did not contain documentation of a discharge summary.
Client # 4 was admitted on 4/7/25 and discharged on 4/11/25. The client record did not contain documentation of a discharge summary.
Client # 5 was admitted on 4/7/25 and discharged on 5/5/25. The client record did not contain documentation of a discharge summary.
Client # 6 was admitted on 4/16/25 and discharged on 5/1/25. The client record did not contain documentation of a discharge summary.
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Plan of Correction
Clinical staff received refresher training on 5/15/25 and 5/21/25 relating to documentation standards. Clinical staff were made aware of necessity to complete a discharge summary for each discharge. BGB will audit a random sampling of no less than 5 charts per month to ensure compliance with this standard, findings will be reporting to the monthly RQM Committee Mtg. The Risk Manager and Clinical Director are responsible for implementation of this POC. |