INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2011 through June 24, 2011 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.
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Plan of Correction
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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 review of personnel records and an interview with the human resource coordinator, the facility failed to ensure that 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.
The findings include:
Employee # 5 was hired as the lead counselor on November 4, 2010. The employee had not functioned as a supervisor for two years and needed the core curriculum training in clinical supervision. Employee# 5 failed to have the core curriculum training in clinical supervision at the time of the inspection.
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Plan of Correction
Employee # 4 and Employee # 5 will register for the anticipated December 2011 Clinical Supervision training when the registration becomes available in late August 2011.
Any subsequent hires into these roles will be registered for this training timely, however, based on training availability. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records and an interview with the human resource coordinator and facility director, the facility failed to provide documentation of HIV/AIDS training in two out of twenty records reviewed.
The findings include:
Twenty personnel records were reviewed on June 21, 2011. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee #11 was hired 4/5/2010 as a counselor assistant. This employee was required to obtain six hours of HIV/AIDS the training by 4/5/2011. Employee # 11 failed to obtain the training as of the date of the inspection.
Employee # 14 was 6/9/2008 as a LPN. This position is considered a support staff position and was required to obtain six hours of HIV/AIDS training by 6/9/2010. Employee # 14 failed to obtain the training as of the date of the inspection.
The facility director and human resource director were interviewed and confirmed these employees had not completed the required HIV/AIDS training.
This is a repeat citation from the June 7 through 9, 2010 inspection, as well as the March 4, 2011 follow-up inspection.
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Plan of Correction
Employee # 11 and Employee # 14 are registered for HIV/Aids training on September 19, 2011.
Ongoing mandatory training compliance will be done through a tracking system maintained by the HR coordinator. The Department Supervisors are responsible for assuring their staff are held accountable to being compliant with such training requirements. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel and training records, administrative documentation, and an interview with the human resource coordinator, the facility failed to have sufficient staff with CPR certification and first aid training.
The findings include:
Twenty employee records were reviewed along with the Staffing Requirements Facility Summary Report. Six employees were drivers. Drivers are alone with clients when they are transported to and from the facility and require CPR certification and First Aid training. Documentation of CPR and First Aid cards were reviewed for those staff who had obtained the training. It was observed that none of the facility drivers had obtained CPR certification and First Aid Training. Employees # 15, 16, 17, 18, 19, and 20 failed to have the required training.
An interview with the human resource coordinator confirmed that these employees did not have the required training.
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Plan of Correction
Employee # 15, 16, 17, 18, 19 and 20 attended CPR training conducted by our Local Red Cross on 6/29/2011.
Compliance of mandatory trainings will be done by a tracking system maintained by the HR Coordinator.
Department Supervisors will be responsible for holding thier staff accoutnable to such training requirements. |
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 observation, a physical plant inspection and an interview with the maintenance director, the facility failed to 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 findings include:
A physical plant inspection was conducted on June 23, 2011 from 9:15 a.m. until 10: 15 a.m. During the physical plant inspection the following areas were observed and deemed to be not in good repair:
1. Room # 4 was observed to have a crack in the ceiling approximately 12 inches long.
2. Room # 25 was observed to have approximately six feet by four inches of the plaster coming off the wall above the heating unit that was in need of repair.
3. Room # 27 was observed to have a sink with water damage to the foundation of the vanity. There was a one and a half foot by three inch area at the bottom of the vanity that had been removed.
An interview with the maintenance director was conducted and confirmed the findings.
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Plan of Correction
All deficient areas observed with corrected by the Maintenance Staff as of 6/27/2011.
A maintenance log is kept for all areas in need of repair. Each item is prioritized and corrected, then date of such repair is then logged.
It is the responsibility of the Maintenance Supervisor to assure all repairs are assessed for priority and completed in a timely manner via review of the Maintenance Log on a daily basis. |
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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records the facility failed to document the purpose of disclosure for voluntary consent to release information in six of fifteen client records reviewed.
The findings include:
Fifteen client records were reviewed on June 23-24, 2011. Six of fifteen records contained a consent to release information that failed to include a purpose for the disclosure of information.
Client record # 2 contained a consent to release information form for the probation officer and a specified county. Both consent forms failed to include the purpose of disclosure. This area of the release of information form was left blank.
Client record # 3 contained a blank consent that failed to include the purpose for the release of information. An area identified on the form for this information was left blank. This record also contained a release for the insurance company that did not indicate what was going to be released and the purpose of the disclosure.
Client record # 5 contained a consent to release information to a specific county but failed to specify the purpose for the release of information.
Client record # 10 contained a consent for the employer that failed to include a purpose for the disclosure of information that clearly indicated a purpose that was logically consistent with the function of the recipient. The purpose of the disclosure for this consent was, "physician of care, treatment plan, and discharge planning."
Client record # 12 contained a consent for the probation officer that failed to include a purpose for the disclosure of information that clearly indicated a purpose that was logically consistent with the function of the recipient. The purpose of the disclosure was, "physician of care, treatment plan, and discharge plan."
Client record # 15 contained a consent for the employer that failed to include a purpose for the disclosure of information that clearly indicated a purpose that was logically consistent with the function of the recipient. The purpose of the disclosure was, "progression in care."
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Plan of Correction
All appropraite staff will be retrained in the proper completion and execution of Consent Forms. Each departmental supervisor will be responsibel for their department training: Director of Admissions, Director of Nursing and Clinical Director. Ongoing compliance will be maintained via randome chart audits done on a weekly basis with feedback given to staff. If a pattern with staff is noted, then the disciplinary process may be implemented. Additionally, the Medical Records Director will be responsible to assure 100% of charts are audited related to this issue and deficiences be noted to staff and supevisors. |
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 records.
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Observations
Based on the review of the client records the facility failed to document that a copy of a client consent was offered to the client in four of fifteen records.
The findings include:
Fifteen client records were reviewed on June 23 through 24, 2011. All records had consent to release forms that required the client to be offered a copy of the consent. The facility failed to document whether a copy of the consent was offered to the client in records # 1, 2, 3, 10 and 14.
Client record # 2 had a consent signed for a specific county. The facility failed to document whether a copy of the consent was offered to the client.
Client record # 3 had a consent signed for the insurance company and the emergency contact. The facility failed to document whether a copy of the consent was offered to the client for both of these consents.
Client record # 10 had a consent signed for the funding source. The facility failed to document whether a copy of the consent was offered to the client.
Client record # 14 had a consent for an outpatient provider. The facility failed to document whether a copy of the consent was offered to the client.
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Plan of Correction
All appropraite staff will be retrained in the proper completion and execution of Consent Forms. Each departmental supervisor will be responsibel for their department training: Director of Admissions, Director of Nursing and Clinical Director. Ongoing compliance will be maintained via randome chart audits done on a weekly basis with feedback given to staff. If a pattern with staff is noted, then the disciplinary process may be implemented. Additionally, the Medical Records Director will be responsible to assure 100% of charts are audited related to this issue and deficiences be noted to staff and supervisors. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on review of the policy and procedure manual, observation, review of pharmacy inspection reports, and an interview with the director of nursing, the facility failed to have topical medication stored separately from oral medication.
The findings include:
The policy and procedure manual was reviewed on June 22, 2011. According to the policy and procedure manual the medication storage policy stated, "External use drugs in whatever form shall be stored separately from drugs for internal use and in a section marked externals." The nurses station was inspected on June 22, 2011 at 1:05 p.m. The medication carts were inspected and it was observed that the topical medications were being stored with the oral medications. The topical medications were stored in ziplock bags with the oral medications. The Pharmacy report from 3/23/2011 was reviewed and this report indicated that internal and external medications were not being stored separately.
The Director of Nursing confirmed this finding.
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Plan of Correction
As of 6/22/2011, all External Medications are stored separately in a designated area of the Medication Cart.
The Director of Nursing or Assistant Director of Nursing will monitor this practice on a weekly basis to assure ongoing compliance. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on the review of the policy and procedure manual, client records and an interview with the clinical supervisor and director of nursing, the facility failed to document discharge summaries in two of two required records.
The findings include:
The policy and procedure manual was reviewed on June 22, 2011. According to the policy and procedure manual discharge summaries are to be completed within seven days of discharge. Five detox records were reviewed on June 23 through June 24, 2011. Two of those records were of discharged clients and required a discharge summary. Client records # 4 and 5 failed to have a completed discharge summary.
Client # 4 was admitted on 2/21/2011 and was discharged on 2/25/2011. A discharge summary was due by March 4, 2011. As of the date of inspection the facility failed to document a discharge summary in this record.
Client # 5 was admitted on 2/21/2011 and was discharged on 2/23/2011. A discharge summary was due by March 2, 2011. As of the date of inspection the facility failed to document a discharge summary in this record.
An interview with the clinical supervisor and director of nursing confirmed this finding.
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Plan of Correction
Director of Nursing re-oriented all Nursing Staff to Discharge Summary Requirements related to patients who discharge out of Detox.
Director of Nursing will maintain ongoing compliance by completing random weekly chart audits on those patients who discharge from Detox. Those staff responsible will be given feedback if they are deficient and if a pattern is noted, disciplinary steps may be taken.
Additionally, the Medical Records Director will assure that 100% of charts are audited for this standard and note deficiencies to responsible staff and supervisors. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of client records and an interview with the clinical director and director of nursing, the facility failed to file a written Unusual Incident Report with the Department within 48 hours following an unusual incident.
The findings include:
Fifteen records were reviewed on June 23-24, 2011. One client record required an incident report to be filed with the Department within 48 hours of the occurrence. Client record # 15 indicated that the client had distributed benzodiazepines to another client at the facility. The patient who received the benzodiazepines became unresponsive and was sent to the hospital. The facility failed to submit a written report to the Department. An interview with the Director of Nursing and Clinical Supervisor on June 24, 2011 at 11:00 a.m. confirmed this finding.
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Plan of Correction
Executive Director redistributed criteria for circumstances warranting a state incident report.
For every internal incident report that is written, the Director of Nursing and the Clinical Director will review against these criteria and execute a State Incident Report within 48 hours where warranted.
The Executive Director will be responsible for double checking all incident reports and assure those meeting the State Criteria were actually completed. |