INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20 through 22, 2007 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 September 20, 2007.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of administrative documentation and policy and procedure manuals, the facility failed to document a written compliance plan by the governing body that verified the intent of the project to comply with Chapter 704.
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Plan of Correction
Compliance plan written by this Executive Director and ready to be submitted for governing body approval at Q3 2007 meeting scheduled 11/14/07.
Minutes will reflect governing body approval.
This Executive Director will assure this is completed annually during Q1 Governing Body reports to remain in compliance with this standard.
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure the project director met the educational qualifications for this position.
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Plan of Correction
Currently identified Project Director will submit current resume, college transcripts as well as a letter from his accredited college indicating that his college degree is related to Business Management for reconsideration by DAPL. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of policy and procedure manuals, the facility failed to document a complete staff development policy and procedure. The staff development policy and procedure did not address a mechanism to collect feedback for training received outside of the project or the annual evaluation of the overall training plan.
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Plan of Correction
The policy reviewed only indicated "in-service" needed an evaluation. This Executive Director added verbiage indicating that any outside trainings also need an evaluation.
This Executive Director is also in the last stages of completing a new Policy and Procedure manual. This related policy will, as well, have proper verbiage related to an evaluation being needed for in-services and outside trainings.
New Policy And Procedure Book: Target to be in place by 10/15/07. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documentation, the facility failed to complete an annual evaluation of the overall training plan for the 2006 training year.
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Plan of Correction
It is the Administrative Assistant's responsibility to assure this form is completed on an annual basis.
The form is in appropriate place at this time. This Executive Director will monitor annually as well to assure it is completed and in proper place in manual for any further licensing/auditng purposes.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection conducted August 22, 2007 at 1:30 p.m., the facility failed to store all trash in a covered container. Trach cans located in the kitchen were not covered.
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Plan of Correction
All trash cans in the kitchen area have an associated lid. All kitchen staff have been re-trained on the importance of covering the trash cans by the Food Service Director on 8/22/07.
Daily checks will be done by supervisor on duty to assure ongoing compliance with state regulation. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection conducted August 22, 2007 at 1:30 p.m. and a review of the freezer temperature log, the facility failed to keep frozen food at or below 0 degrees Fahrenheit. The freezer temperature log documented freezer temperatures between 2 degrees and 14 degrees Fahrenheit for 12 of 22 days in August 2007.
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Plan of Correction
Both freezers were recalibrated on 8/24/07 as well as serviced. Freezers are maintained at 0 degrees Farenheit. On 8/25/07, the Food Service Director retrained all kitchen staff NOT to take temperature readings while Freezers are in Defrost Cycle.
Daily temperature readings will be done by supervisor on duty to assure ongoing compliance with state regulations. Service will be conducted on freezers as necessary. |
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 and training records, the facility failed to document fire extinguisher training for one of three employees reviewed, #11.
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Plan of Correction
Contracted employee # 11, scheduled for Fire Safety training within next 7 days by Safety Officer. This is medical director and have found it a bit difficult to pin down a time.
It continues to be responsibility of the Safety Officer to assure this is done within the 7 day standard.
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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 and training records, the facility failed to document emergency training for one of three employees reviewed, #11.
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Plan of Correction
Contracted employee # 11, scheduled for Emergency training within next 7 days by Safety Officer. This is medical director and have found it a bit difficult to pin down a time. It continues to be responsibility of the Safety Officer to assure this is done within the 7 day standard.
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709.82(a) 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:
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Observations
Based on a review of client records, the facility failed to complete an individual treatment plan for clients transferred to the partial hospitalization level of care in five of six client records reviewed, #11, 12, 13, 14 and 15.
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Plan of Correction
Clinical Director will hold a clinical staff meeting/in-service by 9/21/07 to review clinical documentation, the proper procedure for stepping a patient down from one level of care to the next, and the proper documentation. This procedure will include:
A note to notify medical of the transfer of level of care, a progress note documenting the transfer level of care, a case consult, a notation on the Clinical Master Problem List, and a new treatment care plan will be established with the patient addressing areas they will work on at this level of care.
Plan of correction will be monitored during monthly supervision and during the clinical chart audit.
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709.82(a)(1) 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:
(1) Short- and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to complete an individual treatment plan for clients transferred to the partial hospitalization level of care in five of six client records reviewed, #11, 12, 13, 14 and 15.
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Plan of Correction
Clinical Director will hold a clinical staff meeting/in-service by 9/21/07 to review clinical documentation, the proper procedure for stepping a patient down from one level of care to the next, and the proper documentation. This procedure will include:
A note to notify medical of the transfer of level of care, a progress note documenting the transfer level of care, a case consult, a notation on the Clinical Master Problem List, and a new treatment care plan will be established with the patient addressing areas they will work on at this level of care.
Plan of correction will be monitored by Clinical Director during monthly supervision and during the clinical chart audit.
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709.82(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to complete an individual treatment plan for clients transferred to the partial hospitalization level of care in five of six client records reviewed, #11, 12, 13, 14 and 15.
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Plan of Correction
Clinical Director will hold a clinical staff meeting/in-service by 9/21/07 to review clinical documentation, the proper procedure for stepping a patient down from one level of care to the next, and the proper documentation. This procedure will include:
A note to notify medical of the transfer of level of care, a progress note documenting the transfer level of care, a case consult, a notation on the Clinical Master Problem List, and a new treatment care plan will be established with the patient addressing areas they will work on at this level of care.
Plan of correction will be monitored by Clinical Director during monthly supervision and during the clinical chart audit.
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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 complete an individual treatment plan for clients transferred to the partial hospitalization level of care in five of six client records reviewed, #11, 12, 13, 14 and 15.
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Plan of Correction
Clinical Director will hold a clinical staff meeting/in-service by 9/21/07 to review clinical documentation, the proper procedure for stepping a patient down from one level of care to the next, and the proper documentation. This procedure will include:
A note to notify medical of the transfer of level of care, a progress note documenting the transfer level of care, a case consult, a notation on the Clinical Master Problem List, and a new treatment care plan will be established with the patient addressing areas they will work on at this level of care.
Plan of correction will be monitored by Clinical Director during monthly supervision and during the clinical chart audit.
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709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of administrative documentation, the facility failed to provide documentation that legal services were available to clients.
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Plan of Correction
Administrative Assistant obtained properly executed Legal Referral Agreement 9/18/07.
The Referral Agreement book will be monitored annually by Administrative Assistant and this Executive Director to assure all referral agreement are up to date and assure that all required entities are represented in our referral agreement book.
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709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on a review of the facility's policy and procedure and client records, the facility failed to document the plan portion of the progress note for group sessions in six of six client records reviewed, #11, 12, 13, 14, 15 and 16.
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Plan of Correction
A new group note form will be developed by Clinical Director and approved by this Executive Dirctor.
This new form will then be reviewed with all clinical staff by the clinical director and implemented by 9/26/07. This note can be used for both written and typed notes.
In addition - this meeting will
review clinical documentation and the proper procedure for completing a Group Note.
Plan of correction will be monitored by the Clinical Director during monthly supervision and chart audits.
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709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on the physical plant inspection and staff interviews, the facility failed to display the project's hours of operation for the partial hospitalization activity.
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Plan of Correction
Project's hours of operation for partial hospitalization activity posted on main facility entrance doorway 9/17/07.
This standard will be monitored by this Executive Director during standard facility walk throughs. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on the physical plant inspection and staff interviews, the facility failed to display the project's telephone number for emergency purposes to the general public.
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Plan of Correction
Emergency Phone # posted on main facility entrance doorway 9/17/07. This standard will be monitored by this Executive Director during standard facility walk throughs. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the annual report, the facility failed to include a statement disclosing the names of officers, directors and principal shareholders.
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Plan of Correction
Principal shareholders will be listed in Q3 2007 Governing Body Report - meeting scheduled for 11/14/07. This list will be reflected in the minutes as an addendum to the 2007 annual report.
Administrative Assistant and this Executive Director will be responsible for assuring that this piece of information is included in all further annual reports. |
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 a review of five policy and procedure manuals, the facility failed to annually update the manual. Conflicting policies and procedures were documented for the completion of clinical record components including physical examinations, psychosocial assessments, integrated summaries, treatment plans and follow up information. Two different policies and procedures were documented for staff to access client records and the retention of client records.
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Plan of Correction
This Executive Director is in the last stages of completing a new Policy and Procedure manual. New Policy And Procedure Book: Target to be in place by 10/15/07.
After implementation - Administrative Assistant and this Executive Director will be responsible for assuring that all P & P books are reviewed and updated as needed, but no less than annually. A document with this Executive Director's signature will be placed in the front of the manual to document this has occurred each year. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection conducted on August 22, 2007 at 1:30 p.m., the facility failed to secure active client records. Client records were stored in an unlocked storage container in the nursing area next to a seat where client sit for assessments.
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Plan of Correction
A lateral locking filing cabinet was placed in the nursing area on 9/6/07. All active charts are now housed in this locking filing cabinet.
Director of Nursing and each shift designee will responsible to assure all charts are secured in this locking filing cabinet when not in use by appropriate staff. |
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 shall be in writing and shall 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 an informed consent from the client in five of sixteen records reviewed, #5, 6, 7, 11 and 12. The name of the person, agency or organization was not documented on consents that clients had signed for a physician or for payment. These consents stated "no doctor" or "self pay".
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Plan of Correction
Consent form for Primary Care Physician revised to include the exception "I do not have a primary care physician" witha signature line associated with that.
Self-pay patients will have not have associated consent.
Upon state approval, forms will replace existing consent form. Admissions Director will monitor admissions charts to assure ongoing compliance.
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709.64(c)(3) LICENSURE Legal support service
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of administrative documentation, the facility failed to provide documentation that legal services were available to clients.
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Plan of Correction
Administrative Assistant obtained properly executed Legal Referral Agreement 9/18/07.
The Referral Agreement book will be monitored annually by Administrative Assistant and this Executive Director to assure all referral agreement are up to date and assure that all required entities are represented in our referral agreement book.
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709.51(a)(3) LICENSURE Tx Completion Requirements
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
Based on a review of the facility's policy and procedure manuals, the facility failed to document a written plan for the requirements for completion of treatment. A plan was not documented for the inpatient non-hospital activity.
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Plan of Correction
The Executive Director is in the last stages of revamping all policy and procedure manuals - goal to be done by 10/15/07. Missing level of care completion requirements will be added.
Ongoing updates of manual will be done as needed and at least annually by Administrative Asst and Executive Director to assure all necessary policies are included and correct.
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709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of administrative documentation, the facility failed to provide documentation that legal services were available to clients.
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Plan of Correction
Administrative Assistant obtained properly executed Legal Referral Agreement 9/18/07.
The Referral Agreement book will be monitored annually by Administrative Assistant and this Executive Director to assure all referral agreement are up to date and assure that all required entities are represented in our referral agreement book.
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of the facility's policy and procedure and client records, the facility failed to document the plan portion of the progress note for group sessions in seven of seven client records reviewed, #2, 3, 4, 5, 7, 8 and 10.
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Plan of Correction
A new group note form will be developed by Clinical Director and approved by this Executive Dirctor.
This new form will then be reviewed with all clinical staff by the clinical director and implemented by 9/26/07. This note can be used for both written and typed notes.
In addition - this meeting will
review clinical documentation and the proper procedure for completing a Group Note.
Plan of correction will be monitored by the Clinical Director during monthly supervision and chart audits.
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