INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9,10, and 11, 2013 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, BGI of Brandtwine, 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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704.11(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 staff development records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of nine personnel records reviewed.
The findings included:
Eleven personnel records were reviewed on July 11, 2013. Nine personnel record were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 11 and 12.
Employee # 11 was hired on August 10, 1998. The facility training year is from January through December. The training year for January 2012 to December 2012 was reviewed. Employee #11 completed 13.5 clock hours of annual training in 2012.
Employee # 1 was hired on September 6, 2011. The facility training year is from January through December. The training year for January 2012 to December 2012 was reviewed. Employee #12 completed 8 clock hours of annual training in 2012.
The Human Resource Director confirmed on July 11, 2012 that the above references personnel did not have the required 25 clock hours of training for the 2012 training year.
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Plan of Correction
All clinical staff will be re-oriented to the procedures related to acquiring thier required calendar year training by the Interim Clinical Director.
Clinical Supervisors and Interim and upcoming permanent Clinical Director have or will have placed quarterly reminders on their calendar to discuss progress during clinical supervision to assure this standard is in compliance.
Any staff member not in compliance will be placed in disciplinary action.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a review of the physical plant on July 11, 2013, the facility failed to have the building free of hazards and the safety and well-being of the residents living there.
The findings include:
The facility's physical plant was inspected on July 11, 2013. The bathroom on the first floor of the men's residential area, specifically room # 18, had a very strong odor of mildew and the ceiling of the shower stall was removed with all the pipes exposed. The maintenance supervisor stated there was a repair for a leak into that space in the past week.
During the physical plant inspection, the licensed specialist observed patients who were complaining about the odor from room # 18.
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Plan of Correction
Room # 18 was scrutized by the Plant Operations Supervisor and all necessary repairs and remediations were completed by 7/24/2013.
Rooms are inspected daily by POS or a delegate to assure compliance with all physical plant standards. Additionally, all daily room inspections will be documented and kept in POS office. |
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 the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 findings include:
The physical plant inspection took place on July 11, 2013. At 11:30 a.m. the water temperature was tested in the bathroom and it read 129 The maintenance supervisor adjusted the temperature on the water heater while the licensing specialist was at the facility.
The maintenance supervisor confirmed the temperatures exceeded the required 120
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Plan of Correction
Plant Operations Supervisor contacted outside agency to assure this deficiency was corrected. A faulty high limit switch was found and this issue was rectified on 7/17/2013.
Temperature testing of this unit will be part of the daily maintenance inspection report that is done by POS or designee with corresponding documention kept in POS office. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a Psychosocial evaluation in three client records.
The findings include;
Eleven client records were reviewed on July 10, 2013. Psychosocial Evaluations were required in eleven client records. Three client records failed to have a Psychosocial evaluation completed and documented in the client record.
Client #3 was admitted on November 27, 2013. The client history was completed on November 28, 2013 but there was no documentation of a psychosocial evaluation in the client record,
Client # 4 was admitted on February 10, 2013. The client history were completed on February 10, 2013 but there was no documentation of a psychosocial evaluation in the client record,
Client #10 was admitted on June 27, 2013. The client history were completed on June 29, 2013 but there was no documentation of a psychosocial evaluation in the client record,
The administrative assistant confirmed on July 11, 2013 all three Psychosocial Evaluations were not completed.
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Plan of Correction
Interim Clinical Director will conduct a Lunch and Learn on 8/13/2013 to re-orient all clinical staff on the requirements of the clinical chart. Additionally, the 2 Clinical Supervisors will institute a Peer Review Process will begin 9/2/2013.
Weekly chart audits by Clinical Director and Clinical Supervisors will assure ongoing compliance with this standard. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on the review of the client records, the facility failed to document counseling sessions on the record of service in four of eight client records.
The findings include:
Eight client records were reviewed on July 10,2013. The following client records failed to include a record of service:
Client #5 was admitted on June 17, 2013. There was no documentation of a record of services available for review.
Client # 6 was admitted on May 29, 2013. There was no documentation of a record of services available for review.
Client #7 was admitted June 19, 2013. There was no documentation of a record of services available for review.
Client # 8 was admitted on June 11, 2013. There was no documentation of a record of services available for review.
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Plan of Correction
Interim Clinical Director will conduct a Lunch and Learn on 8/13/2013 to re-orient all clinical staff on the requirements of the clinical chart. Additionally, the 2 Clinical Supervisors will institute a Peer Review Process will begin 9/2/2013.
Weekly chart audits by Clinical Director and Clinical Supervisors will assure ongoing compliance with this standard. |