INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on October 12, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, BGI Brandywine Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
709.28 (c) 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.
|
Observations
Based on a review of one internal unusual incident report on 10/12/21, the facility failed to obtain a consent to release to disclose client ' s information to the local police.
The police came onsite on 7/22/21 and inquired about the client ' s medication. Identifying information was given without a consent to release on file.
The finding was discussed with the facility staff during the compliant investigation.
|
Plan of Correction
Staff will be re-trained on the confidentiality laws specifically in relation to releasing information to law enforcement without client consent. The CEO or designee will review incident reports monthly to ensure compliance. |
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.
|
Observations
Based on a review of one internal unusual incident report on 10/12/21, the facility failed to send the unusual incident to the Department of Drug and Alcohol Programs as required.
Documentation in the unusual incident stated that the local police was on site on 7/22/21.
The finding was discussed with facility staff during the complaint investigation.
|
Plan of Correction
Staff have been re-trained on the regulations regarding unusual incident reporting and the need to report these timely. The CEO or designee will review incident reports monthly to ensure compliance. |