INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, and inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine in the treatment of narcotic addition. This inspection was conducted on June 10 - 11, 2015 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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704.11(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 administrative documentation, the facility failed to provide a comprehensive staff development program.
The findings include:
On June 10 - 11, 2015, the facility's comprehensive staff development program was requested. The facility failed to provide a comprehensive staff development program which included an assessment of staff training needs, an overall plan for addressing these needs, and an annual evaluation of the overall training plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a Comprehensive Staff Develop Plan in accordance with DDAP licensing requirements. Unfortunately, we overlooked submitting it during the licensing visit and can provide to you upon request. It includes an assessment of staff training needs, an overall plan for addressing these needs and an annual evaluation of the overall training plan. We are revising our system for tracking and making this Staff Development Plan a part of QM. QM will begin to track hire dates and training dates. The spreadsheet will be updated and distributed to all managers quarterly so all staff are aware of training needs, requirements, onsite training schedules. The spreadsheet and calendar will be available by 8/15/15. |
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 and a review of the Staffing Requirements Facility Summary Report form (SRFSR), the facility failed to document an annual written individual training plan for employees.
The findings include:
Six personnel records were reviewed for documentation of an individual training plan on June 10, 2015. The facility failed to document an individual training plans in six of six counselor records reviewed; specifically personnel records, # 1, 2, 3, 4, 5 and 6.
In addition, based on an interview with facility staff and documentation on the SRFSR form, at least 20 support staff failed to receive an annual written individual training plan.
The facility's training year was January 1, 2015 to December 31, 2015. All 20 of the support staff were hired prior to the 2014 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. According to an individual?s needs, each staff member will be expected to develop an Individual Training Plan in coordination with, and approval of, their direct Supervisor.
2. Staff members will submit their Individual Training Plan annually.
3. Records of the annual Individual Training Plans will be tracked by the Quality Improvement Department. Records of staff who have yet to complete an Individualized Training Plan will be disseminated to both the employee and their immediate Supervisor.
4. The immediate Supervisor will hold their staff accountable for completing their annual Individual Training Plan
Responsible Person: Director of Quality Improvement, Education and Utilization Review
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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 the Staffing Requirements Facility Summary Report form (SRFSR), the facility failed to ensure staff persons and volunteers received 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.
The findings include:
The SRFSR form was completed by the facility on June 11, 2015. The facility failed to ensure staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours TB/STD training.
Employee # 7, a counselor was hired March 11, 2013. The facility failed to ensure employee # 7 completed HIV/AIDS & TB/STD training by March 11, 2014 or by the time of inspection.
Employee # 8, a counselor was hired January 3, 2013. The facility failed to ensure employee # 8 completed HIV/AIDS & TB/STD training by January 3, 2014 or by the time of inspection.
Employee # 9, a counselor was hired June 3, 2013. The facility failed to ensure employee # 9 completed HIV/AIDS & TB/STD training by June 3, 2014 or by the time of inspection.
Employee # 10, a counselor was hired September 18, 2013. The facility failed to ensure employee # 10 completed HIV/AIDS & TB/STD training by September 18, 2014 or by the time of inspection.
In addition, numerous support staff had not received HIV/AIDS & TB/STD training within the first 2 years of employment, or by the time of inspection.
The administrative assistant was hired June 3, 2013. The facility failed to ensure that the administrative assistant completed HIV/AIDS & TB/STD training by June 3, 2015.
Employee # 11, a receptionist was hired November 27, 2012. The facility failed to ensure that employee # 11 completed HIV/AIDS & TB/STD training by November 27, 2014.
Employee # 12, a receptionist was hired April 17, 2013. The facility failed to ensure that employee # 12 completed HIV/AIDS & TB/STD training by April 17, 2015.
Employee # 13, a maintenance assistant was hired July 7, 2011. The facility failed to ensure that employee # 13 completed HIV/AIDS & TB/STD training by July 7, 2013.
Employee # 14, a maintenance assistant was hired June 23, 2004. The facility failed to ensure that employee # 14 completed HIV/AIDS & TB/STD training by June 23, 2006.
Employee # 15, a patient account rep was hired October 22, 2012. The facility failed to ensure employee # 15 completed HIV/AIDS & TB/STD training by October 22, 2014.
Employee # 16, a nurse assistant was hired November 7, 2012. The facility failed to ensure that the employee # 16 completed HIV/AIDS & TB/STD training by November 7, 2014.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The following staff have been scheduled for training:
Employee #7 is registered to take HIV/AIDS on 9/9/15 and TB/STD on 9/11/15.
Employee #8 resigned effective 7/31/15.
Employee#9 is registered to take HIV/AIDS on 9/9/15 and TB/STD on 9/11/15.
Employee #10 resigned effective 7/10/15.
The Administrative Assistant is registered to take HIV/AIDS on 9/25/15 and TB/STD on 10/2/15.
Employee#11 is registered to take HIV/AIDS on 9/9/15 and TB/STD on 8/5/15.
Employee#12 is registered to take HIV/AIDS on 9/25/15 and TB/STD on 10/2/15.
Employee#13 is registered to take HIV/AIDS on 9/25/15 and TB/STD on 10/2/15.
Employee#14 is registered to take HIV/AIDS on 9/25/15 and TB/STD on 10/2/15.
Employee#15 is registered to take HIV/AIDS on 9/25/15 and TB/STD on 10/2/15.
Employee#16 has been taken off the schedule until she can register for the required trainings.
Furthermore, QM will begin to track hire dates and training dates. The spreadsheet will be updated and distributed to all managers quarterly so staff are aware of the timelines for required trainings.
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form (SRFSR), the facility failed to ensure the residential treatment program maintained one FTE counselor for every eight clients.
The findings include:
The SRFSR form was reviewed on June 10, 2015. The facility provides 460 hours per week for the residential treatment program, and has a total of 110 active clients.
The residential treatment program computation is as follows:
460 hours per week divided by a 35 hour work week = 13.142 full-time equivalent for determining the ratio
110 active clients divided by 13.142 = 8.370 FTE
Their ratio comes out to 9:1
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. A second Clinical Supervisor was hired on July 13, 2015.
2. When a Counselor vacancy occurs, an immediate response will be made to refill the position, including, but limited by, immediately advertising the vacant position.
3. Clinical Supervisors have set aside adequate blocks of time each week to interview potential candidates.
4. Both clinical supervisors are aggressively reviewing resumes, scheduling and conducting interviews to hire for the vacant counselor positions to bring our client/counselor ratios back into compliance. Offers are being made on a timely basis to qualified candidates.
5. As of July 31, we have three pending applicants for vacant positions. Assuming all applicants pass background checks and other preliminaries, Bowling will be in compliance with staffing ratios.
Responsible person: Clinical Supervisors |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
On June 10, 2015, the fire drill logs were reviewed covering the period of May 30, 2014 through May 3, 2015.
The facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The facility documented fire drills during sleeping hours on July 9, 2014 and April 24, 2015.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. Bowling Green maintains a yearly schedule of fire drills
2. Fire drills will be unannounced. The fire drill schedule will be kept confidential, will occur monthly, and consists of quarterly fire drills per shift each year.
a. The knowledge of the fire drill schedule will be disseminated to two maintenance personnel only.
b. Fire drills will be conducted on different days of the week
3. Fire drill procedures will be followed:
a. Notify the fire department that a drill is being conducted
b. Pull the alarm.
c. All personnel and staff will evacuate the premises according to established exit routes and congregate in the pre-established location. Elevators will not be used.
d. Attendance will be taken of all staff and Residents
4. Written fire drill records with date, time, problems encountered, etc. will be maintained.
5. Compliance with the fire drill plan will be tracked by the Maintenance Department and Bowling Green?s Quality Improvement Director.
Responsible persons: Director of Maintenance and Construction Management
Director of Quality Improvement, Education, and Utilization Review |
715.17(c)(2) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(2) Drug storage areas. A narcotic treatment program shall develop and implement written policies and procedures regarding storage of medications and access to the medication storage area. Agents shall be stored in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
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Observations
Based on a physical plant inspection, the facility failed to store narcotic treatment agents in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
The findings include:
A physical plant inspection was conducted on June 11, 2015. The facility failed to maintain narcotics in a separate double-lock box.
Buprenorphine, specifically Subutex was observed in a drawer on the medication cart. The Subutex was not secured in a locked safe as approved by the DEA; in addition, this narcotic was in a drawer with other medication.
"(1) Where small quantities permit, a safe or steel cabinet;"
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
The identified medication cart that was located in the Detox medication room that has the Buprenorphine specifically Subutex was replaced on 6/12/15 with one that has a separate double locked box as required and approved by DEA standards under 21 CFR 1301.72 and 1301.74.(relating to physical security controls; and other security controls.) All Nursing staff was educated on the importance of keeping this medication drawer locked at all times with only Buprenorphine tablets in it on 6/12+15/15. Random checks to ensure the Buprenorphine is in a separate double lock drawer will be completed during our monthly DEA standards audit.
Responsible person: Director of Nursing |