INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 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 LLC, 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel files, the facility failed to ensure that personnel files included documentation of an annual written individual performance evaluation, which shall be reviewed and signed by the employee, in one of two applicable personnel records reviewed.
Employee #1 was hired as a Project Director on September 3, 2020. There was no documentation that the annual written individual performance evaluation was completed for the previous year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon the completion of the site visit, the Facility Director's annual written staff performance evaluation was completed effective May 25, 2022. Moving forward the Human Resource Director with assistance from the Clinical Director will continue to monitor and maintain up to date records of all performance evaluations.
Person(s)Responsible: Human Resources and Clinical Director. |
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 two of seven client records reviewed.
Client #1 was admitted on April 26, 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.
Client #5 was admitted on April 25, 2022 and was discharged May 15, 2022. 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 is a repeat citation from the June 3, 2021 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
We reviewed the previous Plan of Correction and recognize that although the responsible staff member was re-educated on the importance of completing consent/release of information forms prior to disclosure of information, due to staff turnover the change influenced the lack of up to date training in this area. Moving forward the clinical counseling staff will take lead on completing all ROIs during the time of client intake in order to ensure that ROIs are completed timely and accurately. Prior to the client's transition to the Partial Hospitalization Program, all consent forms will be initiated at the time of their rehabilitation level of care with the Lead Rehab Case Manager. The client will meet with Case Management the day before transition and complete all initial ROIs needed for PHP programming.
Upon the official transition to PHP the next day, the client will meet with the PHP case manager who will complete the remaining ROIs as individually needed to ensure that all consent forms are completed timely and accurately.
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.
Person(s) Responsible: Lead Case Manager, Quality Assurance Manager, and Clinical Supervisor. |
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 one of seven client records reviewed.
Client #2 was admitted on April 7, 2022 and was active at the time of inspection. A release of information form was signed and dated by the client on April 7, 2022; however, there was no specific name of the person, agency, or organization to whom the disclosure was to be made documented on the release form.
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. Prior to the client's transition to the Partial Hospitalization Program, all consent forms will be initiated at the time of their rehabilitation level of care with the Lead Rehab Case Manager. The client will meet with Case Management the day before transition and complete all initial ROIs needed for PHP programming. Upon the official transition to PHP the next day, the client will meet with the PHP case manager who will complete the remaining ROIs as individually needed to ensure that all consent forms are completed timely and accurately.
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 the behavioral health tech, case management, and counselor(s) 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.
Person(s) Responsible: Lead Case Manager, Quality Assurance Manager, and Clinical Supervisor. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed.
Client #6 was admitted October 21, 2021 and was discharged November 28, 2021. The release of information form to an emergency contact was signed and dated by the client and witness on October 21, 2021; however, there was no specific information to be disclosed documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Clinical Supervisor will re-educated the behavioral health tech, case management, and counseling 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.
The clinical counseling staff will take lead on completing all ROIs during the time of the client intake in order to ensure that ROIs are completed accurately.
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 will sign off that they were in attendance and received this education. Weekly audits will be conducted by the Clinical Supervisor to verify that all consents to release information have been completed correctly and timely. 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 seven client records reviewed.
Client #2 was admitted on April 7, 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 April 7, 2022; however, the purpose of the disclosure was not documented on the release form.
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.
The clinical counseling staff will take lead on completing all ROIs during the time of the client's intake in order to ensure that ROIs are completed accurately. 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 will sign off that they were in attendance and received this education.
Weekly audits will be conducted by the Clinical Supervisor to verify that all consents to release information have been completed correctly and timely. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision.
Person(s) Responsible: Clinical Director and Clinical Supervisor |
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 dated signature of the client on a release of information form in one of seven client records reviewed.
Client #6 was admitted October 21, 2021 and was discharged November 28, 2021. The release of information form to the funding source was signed by the witness; however, the release form did not have the dated signature of the client documented.
This finding was reviewed 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 counseling, case management, and behavioral health tech staff during their monthly supervision 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.
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.
Person(s) Responsible: Clinical Director and Supervisor & Quality Assurance Manager. |
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 the witness on release of information forms in one of seven client records reviewed.
Client #2 was admitted on April 7, 2022 and was active at the time of inspection. The release of information form to the funding source was signed by the client; however, there was no dated witness signature documented on the release form.
This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
The Clinical Director and Clinical Supervisor will facilitate education and training sessions with the case management, counseling, and behavioral health tech staff during their monthly supervision 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 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. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision.
Person(s) Responsible: Clinical Director and Supervisor |
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 one of seven client records reviewed.
Client #2 was admitted on April 7, 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 April 7, 2022; however, there was no date, event or condition upon which the consent would expire documented on the release form.
This is a repeat citation from the June 3, 2021 annual licensing renewal inspection.
These findings were reviewed 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 counseling, case management, and behavioral health tech staff during their monthly supervision on the requirements of completing release of information forms with the appropriate expiration date of the consent form identified and event or condition of the consent, in accordance to state and federal regulations release of information forms prior to disclosure of information.
Case management and/or counseling staff will sign off as witness on the ROI and document in the clinical progress note that a copy of the ROI has been provided to the client along with identifying the consent form expiration date noted on the ROI as well. All in accordance with state and federal regulation.
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 (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 was offered to the client in two of seven client records reviewed.
Client #6 was admitted October 21, 2021 and was discharged November 28, 2021. The release of information form to the funding source was signed and dated by the client on October 21, 2021; however, there was no documentation that a copy of the form was offered to the client.
Client #7 was admitted November 15, 2021 and was discharged December 16, 2021. The release of information form to the funding source was signed and dated by the client on November 15, 2021; 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.
Person(s) Responsible: Clinical Supervisor and Clinical Director |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one applicable client record reviewed.
Client #4 was admitted on April 4, 2022 and was involuntarily discharged on April 25, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Upon the determination of a client's involuntary termination of their treatment, the client will sign the Bowling Green Notice of Involuntary Discharge form with the clinical counseling staff and the Administrative Discharge or AMA Discharge Premises Notice with nursing staff as part of the signing out process, utilizing both signatures as validation of the client's treatment termination awareness and notification.
Clinical counseling and behavioral health tech staff will be re-educated and trained on the Administrative Discharge Process and/or protocol and all associated documentation during the monthly staff supervision in order to ensure consistency of protocol practice. Both the Director of Nursing and Clinical Director will sign off on all involuntary discharge notifications in order to monitor and ensure that clients are being informed in accordance to regulatory standards.
Person(s) Responsible: Clinical Supervisor, Clinical Director and Director of Nursing |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide a client the opportunity to request reconsideration of a decision to terminate treatment in one of one applicable client record reviewed.
Client #4 was admitted on April 4, 2022 and was involuntarily discharged on April 25, 2022.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Upon the determination of a client's involuntary termination of their treatment, the client has the right to appeal the decision of an Administrative Discharge. Both the Director of Nursing and the Clinical Director will sign off on all involuntary discharge notifications in order to monitor and ensure that clients are being informed in accordance to regulatory standards.
Clinical Director will provide a written notification of the appeal decision within or up to 48 hours of Administrative decision. Clinical counseling and behavioral staff will be re-educated and trained on the Administrative Discharge Process and/or protocol and all associated documentation during the monthly staff supervision in order to ensure consistency of protocol practice.
Person(s) Responsible: Clinical Director |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that individual counseling sessions were provided two times a week in four of seven client records reviewed.
Client #2 was admitted on April 7, 2022 and was active at the time of inspection. There were no documented individual counseling sessions provided for the weeks of May 8, 2022 through May 17, 2022.
Client #4 was admitted on April 4, 2022 and was discharged on April 25, 2022. There were no documented individual counseling sessions provided for the weeks of April 4, 2022 through April 25. 2022.
Client #6 was admitted October 21, 2021 and was discharged November 28, 2021. There were no documented individual counseling sessions provided for the weeks of November 2, 2021 through November 21, 2021.
Client #7 was admitted November 15, 2021 and was discharged December 16, 2021. There were no documented individual counseling sessions provided for the week of December 9, 2021 through December 16, 2021.
This is a repeat citation from the June 3, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
We reviewed the previous Plan of Correction and recognize that although the responsible staff members were re-educated on the importance of conducting individual sessions twice weekly, due to staff turnover the change influenced the lack of up to date training in this area. The clinical counseling staff will be re-educated by the Clinical Supervisor on the standards regarding documentation of an individual session at least twice weekly during staff monthly staff supervision.
Weekly audits will be conducted by the Clinical Supervisor to verify that clinical documentation includes individual sessions two times per week. The Clinical Supervisor will sign off on individual sessions as an additional signature to ensure that the individual sessions are being conducted in accordance to regulatory standards. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision.
Person(s) Responsible: Clinical Supervisor |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include case consultation notes, in four of seven client records reviewed.
Client #4 was admitted on April 4, 2022 and was discharged April 25, 2022
Client #5 was admitted on April 25, 2022 and was discharged May 15, 2022.
Client #6 was admitted October 21, 2021 and was discharged November 28, 2021.
Client #7 was admitted November 15, 2021 and was discharged December 16, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with regulatory standards, case consultation notes will be used to demonstrate the client's involvement in treatment. Case Consultation Meeting with the multidisciplinary team consisting of the case manager, behavioral health tech, clinical supervisor, and counselor(s) will take place weekly which will document concerns, progression, discharge status etc, between the staff members.
Case Consultation notes will be signed by the Clinical Supervisor and all staff in attendance in order to ensure that consultations are occurring weekly.
Chart audits will be conducted at random by the Clinical Director to ensure compliance with the weekly Case Consultation meetings.
Person(s) Responsible: Clinical Supervisor and Clinical Director |
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, the facility failed to document a complete client record, which is to include follow-up information, in two of three applicable records reviewed.
Client #6 was admitted October 21, 2021 and was discharged November 28, 2021.
Client #7 was admitted November 15, 2021 and was discharged December 16, 2021.
This is a repeat citation from the June 3, 2021 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical counseling staff will be re-educated and trained on the standards regarding documentation and maintenance of a record of service form during staff
monthly supervision. During Case Consultation weekly audits will be
conducted by the Clinical Supervisor to verify that clinical documentation includes a record of service. Results of these chart audits will be reported to the Clinical Director and shared with the staff during monthly supervision. |