INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2022 through July 20, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in counseling office-room 11.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Plant Operations Manager or
designee will conduct weekly rounds
of the facility grounds and buildings
and address any concerns within a
reasonable timeframe. The Program
Director will conduct monthly
rounds to ensure ongoing
compliance with this regulation. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
There was a fire extinguisher, located on the exterior of the Motel building next to room 14, that was last inspected in March 2021.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The following deficiencies have
been addressed:
**The fire extinguisher was updated effective July 20, 2022 The
Plant Operations Manager has since
implemented a weekly check of all
items related to Fire Safety (signs,
doors, extinguisher, etc) for all buildings on 8/1/22. The documentation of these checks will be reviewed during the monthly Safety Committee meetings
to ensure compliance.
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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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form for the disclosure of information in the client record in one of fifteen client records reviewed.
Client #2 was admitted on July 15, 2022 and was active at the time of inspection. There was documentation of billing to the funding source during the client's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Ongoing training and education on
the standards related to completing a
consent to release information form
prior to disclosure will be conducted
during monthly staff supervision.
Staff such as counselor(s), case
management, behavioral health tech
(s), and clinical supervisor will sign
off that they were in attendance and
received this education.
Over the next several months
bi-weekly audits will be conducted
by the Quality Assurance Manager
and Medical Records Manager to
verify that all consents to release
information have been completed
accurately and timely. After these
few months, the Clinical Supervisor
will take lead on the chart audits.
Results of these chart audits will be
reported to the Clinical Director and
shared with the staff during monthly
supervision. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on informed and voluntary consent to release information forms in two of fifteen client records reviewed.
Client #2 was admitted on July 15, 2022 and was active at the time of inspection. A release of information form was signed and dated by the client on July 15, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #4 was admitted on June 28, 2022 and was discharged on July 5, 2022. A release of information form was signed and dated by the client on June 28, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director and Clinical
Supervisor will re-educated the
counselor(s), behavioral health tech,
and case management staff on the
requirements of completing release
of information forms fully (including
but not limited to information to be
disclosed, name of client, purpose of
disclosure, appropriate dates and
signatures, etc) in accordance to
state and federal regulations release
of information forms prior to
disclosure of information.
The clinical counseling staff will
complete all ROIs during the time of
client intake in order to ensure that
ROIs are completed accurately.
The Quality Assurance
Manager and Medical Records
Manager will be responsible for auditing charts on a bi-weekly basis to verify that all consents to release information have been completed accurately and timely.
After a few audits, the Clinical
Supervisor will take lead on the chart
audits. Results of these chart audits
will be reported to the Clinical
Director and shared with the staff
during monthly supervision. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in one of fifteen client records reviewed.
Client #11 was admitted on June 23, 2022 and was active at the time of inspection. The release of information form to a funding source was signed and dated by the client on June 23, 2022, but the form did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director and Clinical
Supervisor will re-educate the
counseling, behavioral health tech,
and case management staff on the
requirements of completing release
of information forms fully (including
but not limited to information to be
disclosed, purpose of disclosure,
appropriate dates and signatures,
etc) in accordance to state and
federal regulations release of
information forms prior to disclosure
of information.
Weekly audits will be conducted by
the Clinical Supervisor to verify that
all consents to release information
have been completed correctly |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the date of the client's signature on release of information forms in four of fifteen client records reviewed.
Client #2 was admitted on July 15, 2022 and was active at the time of inspection. The release of information form to the funding source did not include the date of when the client signed the release form.
Client #4 was admitted on June 28, 2022 and was discharged on July 5, 2022. The release of information form to the funding source did not include the date of when the client signed the release form.
Client #10 was admitted on June 23, 2022 and was active at the time of inspection. The release of information form to the funding source did not include the date of when the client signed the release form.
Client #11 was admitted on June 23, 2022 and was active at the time of inspection. The release of information form to the funding source did not include the date of when the client signed the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Since the time of the inspection on July 20, 2022, education and training sessions with the case management, counseling, and
behavioral health tech staff have taken place discussing the the
requirements of completing release
of information forms with the
appropriate consent and expiration date identified and event or condition of the
consent, in accordance to state and
federal regulations release of
information forms prior to disclosure
of information.
Counseling and/or Case
Management staff will sign off on
the ROI and document in their
clinical progress note that a copy of
the ROI has been provided to the
client with the date that such
document was signed also, in
accordance with state and federal
regulation. Weekly audits will be
conducted by the Clinical Supervisor
to verify that all consents to release
information have been completed
correctly and timely. |
709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on release of information forms in four of fifteen client records reviewed.
Client #2 was admitted on July 15, 2022 and was active at the time of inspection. The release of information form to the funding source was signed and dated by the client; however, the form did not include the dated signature of a witness.
Client #4 was admitted on June 28, 2022 and was discharged on July 5, 2022. The release of information form to the funding source was signed and dated by the client; however, the form did not include the dated signature of a witness.
Client #10 was admitted on June 23, 2022 and was active at the time of inspection. The release of information form to the funding source was signed and dated by the client; however, the form did not include the dated signature of a witness.
Client #11 was admitted on June 23, 2022 and was active at the time of inspection. The release of information form to the funding source was signed and dated by the client; however, the form did not include the dated signature of a witness.
This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
Since the time of the inspection on July 20, 2022 The Clinical Director and Clinical Supervisor facilitated education
and training sessions with the case
management, counseling, and behavioral health tech staff on the importance of signing as witness on all release of information forms, in accordance to state and federal regulations release of
information forms prior to disclosure
of information. Weekly audits will be
conducted by the Clinical Supervisor
to verify that all consents to release
information have been completed
correctly and timely. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire on consent to release information forms in four of fifteen client records reviewed.
Client #2 was admitted on July 15, 2022 and was active at the time of inspection. The release of information form to a funding source was signed and dated by the client and witness on July 15, 2022, but the release form did not document the date, event or condition upon which the consent would expire.
Client #4 was admitted into the detox level of care on June 28, 2022 and was discharged on July 5, 2022. The release of information form to a funding source was signed and dated by the client and witness on June 28, 2022, but the release form did not document the date, event or condition upon which the consent would expire.
Client #5 was admitted on December 4, 2021 and was discharged December 12, 2021. The release of information form to a funding source was signed and dated by the client and witness on December 4, 2021, but the release form did not document the date, event or condition upon which the consent would expire.
Client #15 was admitted on November 11, 2021 and was discharged on January 6, 2022. Release of information forms to a treatment facility and government agency were signed by the client and witness on November 4, 2021, but both forms documented that the form would expire on April 4, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Since the inspection on July 20, 2022, the Clinical Director and Clinical
Supervisor facilitated education
and training sessions with the
counseling, case management, and
behavioral health tech staff on the
requirements of completing release
of information forms with the
appropriate expiration date identified
and event or condition of the
consent, in accordance to state and
federal regulations release of
information forms prior to disclosure
of information.
Counseling and/or case management
staff will sign off on the ROI and
document in the clinical progress
note that a copy of the ROI has been
provided to the client also,
indicating the purpose or intent of
the ROI as well in the note. This will
be in accordance with state and
federal regulation.
The Clinical Supervisor will take lead on conducting weekly chart audits to ensure for compliance in this area.
Results of these chart audits will be
reported to the Clinical Director and
shared with the staff during monthly
supervision |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of all informed and voluntary consent to release information forms were offered to the client in one of fifteen client records reviewed.
Client #2 was admitted on July 15, 2022 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on July 15, 2022; however, there was no documentation that a copy of the form was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical
Supervisor will facilitate education
and training sessions with the
clinical counseling staff. The Clinical
Supervisors will review consent
forms for every client record during
supervision weekly to ensure that
the client is receiving a copy of the
form/consent offered. The Clinical
Supervisors will audit 10 charts
weekly and provide feedback during
supervision accordingly. This will
ensure that consent forms are being
filled out correctly on a consistent
basis. The Clinical Director will sign
off on the audit sheets to ensure that
they are being completed weekly. |