INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 2009 through May 29, 2009 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 and a plan of correction is due on June 24, 2009.
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on the review of administrative materials and staff interview, the facility failed to present documentation that their written policy and procedure manual was reviewed annually by the project director.
The findings include:
The facility's policy and procedure manual was reviewed on May 27, 2009. The manual was reviewed and signed by the facility director on January 30, 2009; however, there was no signature by the project director designating that he had reviewed and approved the manual.
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Plan of Correction
On 5/28/09, Project Director signed attestation that policies and procedures manual was reviewed for the 2009 year.
Will be submitting an exception to DAPL asking that current project director be permitted signature authority for this purpose. Letter to be submitted by June 20, 2009
If this exception is not granted, on an annual basis, the project director will review policy and procedures manual and sign an attestation to such. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to prevent the hot water from exceeding 120 degrees Farenheit.
The findings include:
A physical plant inspection was conducted on May 28, 2009 from approximately 1:30pm until 2:30pm. During the physical plant inspection, the hot water temperature registered 125 degrees Farenheit.
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Plan of Correction
Boiler Temperature regulated to appropriate temperature 5/28/09. The temperature fluctuation occurred due to changing from winter to summer boiler - temperature log will be maintained by Maintenance Supervisor to assure that during transition times the timeliness of adjusting the temperature is minimal. |
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records the facility failed to document proposed types of support services on the treatment plan in three of three client records.
The findings include:
Five client records were reviewed on May 28, 2009 through May 29, 2009. A treatment plan with documented support services was required in three client records. The treatment plan did not document support services in client records #16, 17 and 18.
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Plan of Correction
Clinical Director will hold in-service by 6/30/09 with clinical staff reminding them of the required documentation associated with support services.
Ongoing compliance will be monitored via random chart audits and supervision. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on a review of client records and a follow-up log, the facility failed to present documentation that follow-up was conducted in three of five client records.
The findings include:
Five client records were reviewed on May 28, 2009 through May 29, 2009. Follow-up documentation was required in three client records. Documentation of a follow-up letter, as required by the facility's policy and procedure manual, was not presented in client records
# 18, 19 and 20. A follow-up log was presented, which documented in a spread sheet format, the names of the discharged clients and a date that follow-up was conducted but there was no documentation of a follow-up letter.
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Plan of Correction
Medical Records supervisor will place copy of mailed follow up letter in all corresponding charts starting 6/1/09.
Ongoing compliance with this standard will be maintained by Medical Records supervisor utilizing the follow up log indicating the date the letter was sent and final chart audits assuring copy is in chart. |
709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to follow their written policy regarding completion of physical examinations in four of six client records.
The findings include:
Seven client records were reviewed on May 28, 2009 through May 29, 2009. Physical examinations were required in six client records. According to the facility's written policy, physical examinations are to be completed within seventy-two hours of admission. The physical examination was completed more than seventy-two hours after admission in client records #1, 2, 3 and 4. Client records #1, 2 and 3 had physical examinations completed on day four. Client record #4 had a physical examination completed on day five.
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Plan of Correction
Executive Director held in-service with facility Physician Assistant on 6/1/09 re-orienting her to the mandatory timeline to complete a History and Physical - 72 hours from admit.
Ongoing compliance will be monitired via chart audit reports done and submitted by Medical Records Supervisor to Executive Director on a monthly basis.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in one of three client records.
The findings include:
Seven client records were reviewed on May 28, 2009 through May 29,2009. Three client records were required to have completed psychosocial evaluations. A psychosocial evaluation was not documented in client record #7.
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Plan of Correction
In-service to be done by Psychosocial Evaluation Supervisor to Psychosocial staff by 6/30/09 re-orienting them to the mandatory timeline to complete a Psychosocial Evaluatin - 72 hours from admit.
Ongoing compliance will be monitored via random chart audits done monthly by Psychosocial Evaluation supervisor and holding staff accountable to those timelines. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review if client records, the facility failed to document a discharge summary in one of three client records.
The findings include:
Seven client records were reviewed on May 28, 2009 through May 29, 2009. A discharge summary was required in three client records. A discharge summary was not documented in client record #6.
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Plan of Correction
Clinical Director will hold in-service by 6/30/09 with clinical staff reminding them of the required documentation -specifically the discharge summary. Ongoing compliance will be monitored via random chart audits and supervision.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records and a follow-up log, the facility failed to present documentation that follow-up was conducted in three of seven client records.
The findings include:
Seven client records were reviewed on May 28, 2009 through May 29, 2009. Follow-up documentation was required in three client records. Documentation of a follow-up letter, as required by the facility's policy and procedure manual, was not presented in client records #5, 6 and 7. A follow-up log was presented, which documented in a spread sheet format, the names of the discharged clients and a date that follow-up was conducted.
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Plan of Correction
Medical Records supervisor will place copy of mailed follow up letter in all corresponding charts starting 6/1/09.
Ongoing compliance with this standard will be maintained by Medical Records supervisor utilizing the follow up log indicating the date the letter was sent and final chart audits assuring copy is in chart. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records and a follow-up log, the facility failed to present documentation that follow-up was conducted in five of eight client records.
The findings include:
Eight client records were reviewed on May 28, 2009 through May 29, 2009. Follow-up documentation was required in five client records. Documentation of a follow-up letter, as required by the facility's policy and procedure manual, was not presented in client records #11, 12, 13, 14 and 15. A follow-up log was presented, which documented in a spread sheet format, the names of the discharged clients and a date that follow-up was conducted.
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Plan of Correction
Medical Records supervisor will place copy of mailed follow up letter in all corresponding charts starting 6/1/09.
Ongoing compliance with this standard will be maintained by Medical Records supervisor utilizing the follow up log indicating the date the letter was sent and final chart audits assuring copy is in chart. |