INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on May 20, 2024 through May 22, 2024 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present a completed plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit.
As of the date of the inspection, the facility was unable to produce a fully complete and accurate Staffing Requirements Facility Summary Report, which documents staff qualifications and trainings, after multiple attempts at technical assistance by the Department licensing representative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will re-educate HR staff regarding the accuracy of providing a completed Staffing Requirements Facility Summary Report which documents staff qualifications and trainings by June 30, 2024. The HR team will begin working on and completing the Staffing Requirements Facility Summary Report upon receipt and submit timely manner. The Compliance manager will be responsible for the corrective action plan. This will minimize and/or eliminate any additional attempts to obtain when licensing representative is onsite. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of two applicable personnel records reviewed.
Employee #3 was hired as a clinical supervisor on October 1, 2023 and did not have clinical supervision experience prior to being hired. There was no documentation of a Department-approved department approved clinical supervision training on file at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Director will be responsible for ensuring completion of the required department-approved core curriculum in clinical supervision by September 1, 2024. Documentation of completed trainings will be maintained in the employee's file. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the policy and procedure manual and personnel records, the facility failed to develop and document a mechanism to collect feedback on all completed trainings.
The facility's policy and procedure stated employees who attend training sessions paid for by PA facility locations are required to complete a training feedback form and submit it to the QI/Staff development department along with a copy of their training certificates.
The facility was unable to provide training feedback forms for every applicable personnel trainings reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
? The Quality Manager and HR Director will review the policy/procedure manual and personnel records to develop and document a mechanism to collect feedback on all completed trainings July 15, 2024. The HR Director will maintain once mechanism is established. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure written individual training plans were developed with input from both the employee and the supervisor in two of twenty-two personnel records reviewed.
Employee #10 was hired as a counselor on August 30, 2023. The individual training plan was completed on January 4, 2024, but the plan was not signed by the employee and there was no additional documentation indicating the plan was developed with the input of the employee.
Employee #12 was hired as a counselor on October 24, 2023. The individual training plan was labeled 2024, but the plan was not signed by the employee and there was no additional documentation indicating the plan was developed with the input of the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review the written individual training plans with all clinical staff and include any additional documentation regarding their input in the development of their plan by July 15, 2024. The Clinical Director will revisit Employee #10 & Employee #12 written individual training plans to ensure their input is included by July 15, 2024 |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually during the facility's January 2023 through December 2023 training year in three of six applicable personnel records reviewed.
Employee #4 was promoted to a clinical supervisor on March 18, 2024. The employee was initially hired as a counselor on June 16, 2021 and was in the counselor position during the training year reviewed. The personnel record documented 24.15 hours of annual training during the reviewed training year.
Employee #9 was hired as a counselor on September 28, 2022. The personnel record documented 18 hours of annual training during the reviewed training year.
Employee #11 was hired as a counselor on August 3, 2022. The personnel record documented 7 hours of annual training during the reviewed training year.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will complete the 25 hours of required trainings prior to December 31, 2024.
Employee #9 - will complete the 25 hours of required trainings prior to December 31, 2024.
Employee #11 - will complete the 25 hours of required trainings prior to December 31, 2024.
The Quality Manager will be responsible for ensuring completion of the minimal amount of training hours per calendar year in the required areas. Documentation of completed trainings will be maintained in the employee's file.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in one of nine applicable personnel records reviewed.
Employee #12 was hired as a counselor on October 24, 2023. Fire extinguisher training was signed by the supervisor on December 7, 2023; however, the employee did not sign the training and there was no other documentation that the training was provided upon staff employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Plant Operations will train all new hires during orientation regarding the use of fire extinguishers and all new hires will sign the signature page after presentation and they will be forwarded to their supervisor for additional signature by July 15, 2024 |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of nine applicable personnel records reviewed.
Employee #12 was hired as a counselor on October 24, 2023. The emergency preparedness training was signed by the supervisor on December 7, 2023; however, the employee did not sign the training and there was no other documentation that the training was provided to the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Plant Operations will train all new hires during orientation regarding the use of fire extinguishers emergency preparedness and all new hires will sign the signature page and they will be forwarded to their supervisor for additional signature by July 15, 2024. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in five of fourteen applicable client records reviewed.
The facility's policy and procedure manual stated that the emergency contact will be contacted within 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21. Additionally, the policy and procedure manual stated the individual treatment and rehabilitation plan would be completed within 5-7 days of admission into the inpatient non-hospital residential program.
Client #4 was admitted to the inpatient non-hospital detoxification activity on May 10, 2024, and left against medical advice on May 13, 2024. There was no documentation, in the record, that the facility contacted the emergency contact within 12 hours at the time of the inspection.
Client #6 was admitted to the inpatient non-hospital detoxification activity on April 1, 2024, and left against medical advice on April 5, 2024. There was no documentation, in the record, that the facility contacted the emergency contact within 12 hours at the time of the inspection.
Client #9 was admitted to the inpatient non-hospital activity on March 29, 2024 and was discharged on May 20, 2024. The individual treatment and rehabilitation plan was due to be completed by April 5, 2024; however, the plan was signed and completed on April 17, 2024.
Client #13 was admitted to the inpatient non-hospital activity on April 25, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by May 2, 2024; however, the plan was signed and completed on May 10, 2024.
Client #14 was admitted to the inpatient non-hospital activity on April 26, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed by May 3, 2024; however, the plan was signed and completed on May 10, 2024.
This is a repeat citation from the June 9, 2023 annual licensing inspection and the December 12, 2023 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
? Due to employee turnover and lack of communication within departments we have identified our breach in contacting emergency contacts once a client leaves against medical advice. The Clinical Director will re-educate staff on the AMA Policy by July 15, 2024. A signature page will be developed stating understanding. All employees will be required to sign stating they understand the policy and importance of calling the emergency contact within 12 hours when an individual leaves against medical advice.
New employees will be educated on this policy during new employee orientation starting July 2024. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employees file. CEO will ensure compliance.
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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the narcotic treatment program failed to secure a personal history from the patient within the first week of admission in one of seven applicable patient records reviewed.
Patient #9 was admitted to the inpatient non-hospital activity on March 29, 2024, and was discharged on May 20, 2024. There was no documentation of a personal history in the patient record at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will meet with the Medical Director to discuss the importance the narcotic treatment securing clients personal history within the first week of admission.
The DON will review 10 charts for the next 3 months to ensure completion.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records, the facility failed to ensure the individual treatment and rehabilitation plan was developed with the client in two of six applicable client records reviewed.
Client #13 was admitted to the inpatient non-hospital activity on April 25, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed by the medical director on May 10, 2024; however, there was no written documentation that the plan was developed with the client.
Client #14 was admitted to the inpatient non-hospital activity on April 26, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed by the medical director on May 10, 2024; however, there was no written documentation that the plan was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will re-educate clinical staff on developing the treatment plan with the client. This training will occur on July 11, 2024.
If
The clinical supervisors will monitor 10 charts weekly for the next 3 months to ensure that the client was part of the development of their treatment plan. Clinical supervisors will ensure compliance.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days for a client treatment regime that is less than 30 days in two of four applicable client records reviewed.
Client #8 was admitted to the inpatient non-hospital activity on March 5, 2024 and was discharged on April 12, 2024. The individual treatment and rehabilitation plan was completed on March 5, 2024. The first update was due no later than March 20, 2024; however, the update was not completed prior to discharge.
Client #10 was admitted to the inpatient non-hospital activity on March 8, 2024 and was discharged on April 8, 2024. The individual treatment and rehabilitation plan was completed on March 13, 2024. The first update was due no later than March 28, 2024; however, the update was not completed prior to discharge.
This is a repeat citation from the June 9, 2023 annual licensing inspection and the December 12, 2023 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The Clinical Director will re-educate clinical staff on the importance of completing the treatment plan update within the designated time frames with the client. This training will occur on July 11, 2024
If a clinical team member is unable to complete the treatment plan update within the designated time frame, he/she will notify his/her clinical supervisor so arrangements can be made for timely completion.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure treatment plan updates are completed timely. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
Client #8 and #10 are no longer in treatment and the treatment plans are unable to be updated.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of six applicable client records reviewed.
Client #8 was admitted to the inpatient non-hospital activity on March 5, 2024 and was discharged on April 12, 2024. The individual treatment and rehabilitation plan, completed on March 5, 2024, indicated the client was to receive weekly individual counseling sessions. There was no documentation of weekly individual counseling sessions throughout the treatment episode.
Client #9 was admitted to the inpatient non-hospital activity on March 29, 2024 and was discharged on May 20, 2024. The individual treatment and rehabilitation plan, completed on April 17, 2024, indicated the client was to receive weekly individual counseling sessions. There was no documentation of weekly individual counseling sessions occurring during the weeks of April 21, 2024 through May 20, 2024.
Client #10 was admitted to the inpatient non-hospital activity on March 8, 2024 and was discharged on April 8, 2024. The individual treatment and rehabilitation plan, completed on March 13, 2024, indicated the client was to receive weekly individual counseling sessions. There was no documentation of weekly individual counseling sessions throughout the treatment episode.
Client #13 was admitted to the inpatient non-hospital activity on April 25, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan, completed on May 10, 2024, indicated the client was to receive weekly individual counseling sessions. There was no documentation of weekly individual counseling sessions occurring during the week of May 12, 2024 through May 18, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will re-educate clinical staff on the importance of assuring individual counseling services are provided according to the individual treatment and rehabilitation plan.
If the clinical team member is unable to complete the individual session according to the individual treatment and rehabilitation plan he/she will notify his/her clinical supervisor so arrangements can be made for timely completion and follow-up with the client.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure counseling services are provided according to the individual treatment and rehabilitation plan. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
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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, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in two of two applicable client records reviewed.
Client #8 was admitted to the inpatient non-hospital activity on March 5, 2024 and was discharged on April 12, 2024. There was no follow-up information in the record at the time of inspection.
Client #10 was admitted to the inpatient non-hospital activity on March 8, 2024 and was discharged on April 8, 2024. There was no follow-up information in the record at the time of inspection.
This is a repeat citation from the June 9, 2023 annual licensing inspection and the December 12, 2023 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Referral Coordinator will be educated on the importance of doing a 7 day follow up on all clients regardless of where they are going upon discharge from treatment. Follow up will occur even when clients decline aftercare in an effort to see if the client is in need of treatment/recommendations at that time. The Compliance Manager will be responsible for the corrective action is implemented. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the June 9, 2023 annual licensing inspection and the December 12, 2023 provisional license follow-up inspection. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the May 20, 2024 through May 22, 2024, licensing inspection.
A plan of correction for obtaining follow-up information was submitted and approved by the Department for the June 9, 2023 annual licensing inspection and the December 12, 2023 provisional license follow-up inspection. Not obtaining follow-up information was again found to be a deficiency in the May 20, 2024 through May 22, 2024, licensing inspection.
A plan of correction for notifying the emergency contact no later than 12 hours after a client is discharged from the facility against medical advice was submitted and approved by the Department for the June 9, 2023 annual licensing inspection and the December 12, 2023 provisional license follow-up inspection. Failing to notify the emergency contact no later than 12 hours after a client is discharged from the facility against medical advice was again found to be a deficiency in the May 20, 2024 through May 22, 2024, licensing inspection.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will re-educate clinical staff on the importance of completing the treatment plan update within the designated time frames. This training will occur on July 11, 2024.
If a clinical team member is unable to complete the treatment plan update within the designated time frame, he/she will notify his/her clinical supervisor so arrangements can be made for timely completion.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure treatment plan updates are completed timely. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
Due to employee and leadership turnover and lack of communication within departments we have identified the issue.
The Quality manager will facilitate a weekly POC meeting with the leadership team to review POC finding, get up dates on internal findings, assure consistency with the corrective action plan.
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