INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on June 7, 2023 through June 9, 2023 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, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor reviewed met the qualifications of the position in three of fifteen applicable personnel records reviewed.
Employee # 5 was hired as a counselor on August 21, 2022 and was still in the position at the time of the inspection. The employee had a qualifying bachelor's degree; however, there was no documentation that the employee had at least 1 year of clinical experience in a health or human service agency prior to hiring.
Employee # 8 was hired as a counselor on October 19, 2022 and was still in the position at the time of the inspection. The employee had a master's degree; however, there was no documentation provided of the qualifying major, so DDAP was unable to verify the educational qualification.
Employee # 9 was hired as a counselor on July 6, 2022 and was still in the position at the time of the inspection. The employee had a qualifying bachelor's degree; however, there was no documentation that the employee had 1 year of clinical experience in a health or human service agency prior to hiring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 will provide a resume which includes prior experience by August 7,2023. The HR Director will review the resume to ensure employee #5 had one year of clinical experience in a health/human services agency prior to hire. If the employee did not have one year of experience, the employee will be stepped down to a counselor assistant until one year of experience is obtained.
Employee #8 will provide copy of transcript/diploma by August 11, 2023. The HR Director will have the degree verified by August 28, 2023. If the major was not a qualifying major, the employee will drop to a high school level counselor and obtain a qualifying degree or certification within 5 years. If the HR Director does not receive the transcript by August 11, 203 employee # 8 will be removed from the schedule until transcript/diploma is submitted.
Employee #9 will provide a resume which includes prior experience by August 7,2023. The HR Director will review the resume to ensure employee #9 had one year of clinical experience in a health/human services agency prior to hire. If the employee did not have one year of experience, the employee will be stepped down to a counselor assistant until one year of experience is obtained.
The HR Director will have all counselor resumes reviewed by the CEO and/or Quality Director for the next 3 months to ensure all required information is provided. No counselor will receive a start date until the resume is received, experience is documented and/or the major is verified by Sterling (outside vender who does education verifications).
The regional quality director will review the next 6 counselor hires to ensure the correct information is evident in the employee file and the new counselor meets the qualifications to be a counselor.
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor assistant was supervised by a full-time clinical supervisor or counselor in one of one applicable personnel record reviewed.
Employee # 19 was hired as a counselor assistant on January 22, 2023. There was no supervision notes documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #19 will receive close supervision for the next 3 month from a counselor who meets qualifications of 704.6 or 704.7 and/or the clinical supervisor.
The clinical supervisor will maintain a calendar of all supervision dates and documentation supporting the supervision session in the employee file.
The Quality Manager will audit the paperwork from the three months of employee #19s close supervision to ensure completion.
Moving forward, the quality manager will review the supervision level necessary and audit all supervision notes to ensure completion. |
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 records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in four of six applicable personnel records reviewed.
Employee # 5 was hired as a counselor on August 21, 2022 and was due to have HIV/AIDS and TB/STD training no later than August 21, 2022. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 16 was hired as a counselor on June 2, 2022 and was due to have HIV/AIDS and TB/STD training no later than June 2, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 18 was hired as a counselor on March 23, 2022 and was due to have HIV/AIDS and TB/STD training no later than March 23, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 20 was hired as support staff on May 10, 2021 and was due to have HIV/AIDS and TB/STD training no later than May 10, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 will take the required STD/TB training and the required HIV/AIDS training by September 30, 2023.
Employee #16 will take the required STD/TB training and the required HIV/AIDS training by September 30, 2023.
Employee #18 will take the required STD/TB training and the required HIV/AIDS training by September 30, 2023.
Employee #20 will take the required STD/TB training and the required HIV/AIDS training by September 30, 2023.
The HR Coordinator will be responsible for notifying employees of these required trainings and the time frames they must be completed. Documentation of completed trainings will be maintained in the employee's file.
The Quality Management Director will create a spread sheet to track each employee and the required time frame HIV/AIDS and TB/STD training must be completed. The QM director will notify the CEO if an employee is down to 60 days for completion of these trainings. Once these trainings are completed, the QM director will document completion dates on the DDAP staff summary form. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2022 through December 31, 2022 training year in two of three applicable personnel records reviewed.
Employee # 4 was hired as a counselor on September 9, 2020. The personnel record documented 6 hours and 44 minutes of training received during the training year reviewed.
Employee # 14 was hired as a counselor on June 16, 2021. The personnel record documented 22 hours and 6 minutes of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 will complete the 25 hours of required trainings prior to December 31, 2023.
Employee #14 will complete the 25 hours of required trainings prior to December 31, 2023.
The HR coordinator will be responsible for ensuring completion of the minimal amount of training hours per calendar year in the required areas. Documentation of completed trainings will be maintained in the employee's file.
The quality management director will create a spreadsheet composed of counselor name and the required amount of training hours. Upon completion of a training, the quality manager will log the title of the training, hours of the training and date on the spreadsheet. The QM director will send a quarterly update on training hours to the CEO, Clinical director, clinical supervisors and counselors. |
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, the facility failed to ensure that inpatient nonhospital treatment and rehabilitation projects serving adult clients shall have one Full Time Equivalent (FTE) counselor for every eight clients.
The FTE is determined by dividing the total number of hours counselors devoted to their clients (640) by the project workweek (40) = 16. Then, to obtain the overall ratio, the total number of clients on the residential caseload (148) is divided by the FTE (16) = 9.25 or 9:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three detox counselors were moved to the residential program. The current ratio is for clients to staff is 7.89.
The CEO and quality director will ensure compliance.
The CEO/designee will review the total number of clients on campus and the total number of qualified staff on a daily basis for the next three months and monthly thereafter. If appropriate staffing ratios are not met, staffing will be adjusted to include bringing in qualified staff from sister facilities and/or adjusting census to meet standards. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. On June 8, 2023, at approximately 11:05 AM, in the case management area, there was a group counseling session being conducted with the door open.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will re-educate clinical staff on the importance of ensuring privacy according to HIPAA during counseling treatment sessions by August 1, 2023.
The Clinical Director will ensure that all clinical team members close doors during treatment sessions and have noise reductions machines to deter sounds. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to store all utensils in a clean enclosed area. On June 8, 2023, at approximately 11:00 AM, there were boxed plastic utensils, coffee carafes, foil pans and bowls stored on an un-enclosed shelf across from the toilet in the staff bathroom located in the kitchen.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The boxed plastic utensils, coffee carafes, foil pans and bowls will be removed from the staff bathroom by August 4, 2023.
The CEO will meet with the Director of Food and Safety regarding the importance of proper storage of kitchen supplies to ensure safety and freedom of contamination.
The Quality Manager will check the staff bathroom monthly for the next 3 months to ensure there are no dietary supplies in the bathroom area. The quality manager will check for proper storage of utensils in an enclosed area monthly for the next 3 months. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed. At approximately 11:05 AM on June 8, 2023, a space heater was found in an office in the case management area on the first floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater will be removed from the case management office area by August 4, 2023.
The Plant Operations Manager or
designee will conduct weekly rounds
of the facility grounds and buildings
to survey areas for space heaters and/or appliances that are not permitted.
The Quality Manager will conduct, and document, monthly
rounds to ensure ongoing compliance with this regulation. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's August 2022 through May 2023 fire drill log, the facility failed to ensure that all their written fire drill logs included the exit route used and the number of persons in the facility at the time of the drill.
The February 2023 drill log did not include which exit route was used and the October 2022 drill log did not include the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will meet with the Facilities Manager to ensure that all written fire drill logs include the exit route used and the number of persons in the facility at the time of the drill by August 1. 2023
The quality management director will review all drills for the next 3 months to ensure proper completion of all areas on the paperwork. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in three of three applicable client records reviewed.
The facility's policy and procedure manual stated that the emergency contact will be contacted within 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client #1 was admitted to the inpatient non-hospital detoxification activity on May 6, 2023 and left against medical advice on May 7, 2023. There was no documentation of follow-up to the emergency contact within 12 hours, in the record, at the time of inspection.
Client #2 was admitted to the inpatient non-hospital detoxification activity on May 8, 2023 and left against medical advice on May 12, 2023. There was no documentation of follow-up to the emergency contact within 12 hours, in the record, at the time of inspection.
Client #7 was admitted to the inpatient non-hospital detoxification activity on May 7, 2023 and left against medical advice on May 14, 2023. There was no documentation of follow-up to the emergency contact within 12 hours, in the record, at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Manager will re-educate staff on the AMA Policy by August 15, 2023. A signature page will be developed stating understanding. All employees will be required to sign stating they understand the policy and importance of calling within 12 hours when an individual leaves against medical advice. New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training. Signature pages will be kept in the employee's file.
Nursing/clinical staff will inform the emergency contact when a client leaves against medical advice and document contact in the progress notes.
The quality manager will audit the charts of 10 AMA clients monthly for the next 3 months to ensure documentation of notification to the emergency contact occurred. |
709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on an administrative review of the facility policy and procedure manual and unusual incident reports, the facility failed to follow their written procedures for referral outlining cooperation with other service providers including, but not limited to, provision for access to emergency services.
At the time of the inspection, the facility had several policies in place for transporting clients off campus to medical services. Additionally, at intake, the facility had each client sign a transportation contract which stated, "the Bowling Green driver will transport me to and from any appointment arranged by staff and necessary to meet emergent needs while in treatment."
The facility provided a policy, which was updated on June 9, 2023, indicating that a rideshare service could be "utilized for non-emergency medical occurrences for transit"; however, the facility stated that they have been utilizing the rideshare service for medical services and transportation to the local hospital for approximately two and a half years.
Additionally, there were at least 31 unusual incident reports reviewed since the previous inspection in which the facility indicated that a rideshare service was used to transport clients to the emergency room for various medical issues, including serious incidents such as vomiting blood and possible psychiatric emergencies.
None of the transportation policies reviewed, prior to the June 9, 2023 revision, stated that a rideshare service would be utilized to transport client for medical services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Only emergency vehicles and Bowling Green employees who have CPR and are approved to drive will transport clients to the emergency room.
An approved drivers list will be kept the Director of Admissions.
CEO will ensure compliance.
The quality management director will review the files of 5 clients who were transported off campus for medical services each month for the next 3 months to ensure transportation occurred by a BGB employee who was CPR certified and approved to drive. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. On June 8, 2023, at approximately 10:45 AM though 11:05 AM, there were unsecured client records in room # 9 in the mansion, room #5 in the barn, and 2 offices in the case management area.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director and/or quality director will remove all client records from areas other than the chart room by August 4, 2023. This includes any record that may be in the mansion, barn and/or case management area(s).
Staff will be re-educated on the importance of storing charts in the designated chart room which has two locks.
Clinical Director will ensure compliance.
The clinical director and/or quality director will conduct weekly rounds for the next 3 months to ensure client records are in the designated chart room and not in unsecured areas. |
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 and unusual incident reports, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information in one of fifteen client records reviewed and thirty-one unusual incident reports reviewed.
Client #7 was admitted to the inpatient non-hospital detoxification activity on May 7, 2023 and was discharged on May 14, 2023. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Additionally, there were 31 unusual incident reports, involving 31 different clients, in which the facility documented that the clients' full name was disclosed to an external transportation service; however, there were no consent to release information forms signed by any of the clients documented in the records prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will re-educate all staff on the importance of having a consent prior to the release of patient information by August 15, 2023. All employees will be required to sign off stating they understand the policy and the importance of checking for a consent prior to releasing information.
New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance.
Client #7 is no longer in treatment and consent is unable to be redone.
The quality director will review 10 client records per month for the next 3 months to ensure there was an informed consent for any individual/entity that received information related to the client.
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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 is made on a consent to release information form in one of fifteen client records reviewed.
Client # 8 was admitted to the inpatient non-hospital detoxification activity on June 4, 2023 and was still active at the time of the inspection. There was a blank release of information form signed by the client on June 4, 2023; however, the form failed to include the name of the person, agency, or organization to whom the disclosure would be made to.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will re-educate staff who complete consents on the importance of having the name of the person, agency or organization to whom the disclosure is made on all consents by August 15, 2023. All employees who complete consents will sign off stating they understand the policy and the importance of having a name, agency or organization to whom information is being released.
New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance.
Client #8 is no longer in treatment and consent is unable to be redone.
The quality director will review 10 client records per month for the next 3 months to ensure the name of the person, agency, or organization to whom the disclosure is being made is on the consent to release information.
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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 released on consent forms in three of fifteen client records reviewed.
Client #2 was admitted to the inpatient non-hospital detoxification activity on May 8, 2023 and was discharged on May 12, 2023. A release of information form to probation and parole was signed and dated by the client on May 9, 2023; however, the specific information to be disclosed was not included on the consent form.
Client #4 was admitted to the inpatient non-hospital detoxification activity on January 26, 2023 and was discharged on February 28, 2023. A release of information form to a person was signed and dated by the client on January 27, 2023; however, the specific information to be disclosed was not included on the consent form.
Client # 8 was admitted to the inpatient non-hospital detoxification activity on June 4, 2023 and was still active at the time of the inspection. There was a blank release of information form signed by the client on June 4, 2023; however, however, the specific information to be disclosed was not included on the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will re-educate staff who complete consents on the importance of having specific information to be disclosed on all consents by August 15, 2023. All employees who complete consents will be required to sign off stating they understand the policy and the importance of including the specific information to be released.
New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance.
Clients #2, #4 and #8 are no longer in treatment and consent is unable to be redone.
The quality director will review 10 client records per month for the next 3 months to ensure the specific information to be released is on the consent form.
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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 of client records, the facility failed to document the purpose of disclosure on consent forms in two of fifteen client records reviewed.
Client #4 was admitted to the inpatient non-hospital detoxification activity on January 26, 2023 and was discharged on February 28, 2023. A release of information form to a person was signed and dated by the client on January 27, 2023; however, the purpose of the disclosure was not included on the consent form.
Client # 8 was admitted to the inpatient non-hospital detoxification activity on June 4, 2023 and was still active at the time of the inspection. There was a blank release of information form signed by the client on June 4, 2023; however, however, the purpose of the disclosure was not included on the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will re-educate staff who complete consents on the importance of having the purpose of the disclosure on all consents by August 15, 2023. Staff will sign a signature page stating understanding. All employees who complete consents will be required to sign off stating they understand the policy and the importance of including the purpose for the disclosure.
New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance.
Clients #4 and #8 are no longer in treatment and consent is unable to be redone.
The quality director will review 10 client records per month for the next 3 months to ensure the purpose for disclosure is documented on the consent form.
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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 release of information forms in one of fifteen client records reviewed.
Client #4 was admitted to the inpatient non-hospital detoxification activity on January 26, 2023 and was discharged on February 28, 2023. A release of information form to an emergency contact was signed and dated by the client on January 26, 2023; however, the dated signature of the client was not included on the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will re-educate staff who complete consents on the importance of having a dated signature of the client on all consents by August 15, 2023. All employees who complete consents will be required to sign off stating they understand the policy and the importance of having a dated signature for all clients.
New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance.
Client #4 is no longer in treatment and consent is unable to be redone.
The quality director will review 10 client records per month for the next 3 months to ensure the dated signature of the client is on the release of information. |
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 fifteen client records reviewed.
Client # 8 was admitted to the inpatient non-hospital detoxification activity on June 4, 2023 and was still active at the time of the inspection. There was a blank release of information form signed by the client on June 4, 2023; however, the release form did not include the date, event, or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will re-educate staff who complete consents on the importance of having a date, event or condition upon which the consent will expire by August 15, 2023. All employees who complete consents will be required to sign stating they understand the importance of having a date, event or condition upon which the consent will expire.
New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance.
Client #8 is no longer in treatment and consent is unable to be redone.
The quality director will review 10 client records per month for the next 3 months to ensure the date, event or condition upon which the consent will expire is on the release of information. |
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 document that a copy of a client consent was offered to the client in two of fifteen client records reviewed.
Client #2 was admitted to the inpatient non-hospital detoxification activity on May 8, 2023 and was discharged on May 12, 2023. A release of information form to probation and parole was signed and dated by the client on May 9, 2023; however, there was no documentation in the record that a copy of the consent form was offered to the client.
Client # 8 was admitted to the inpatient non-hospital detoxification activity on June 4, 2023 and was still active at the time of the inspection. There was a blank release of information form signed by the client on June 4, 2023; however, there was no documentation in the record that a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will re-educate staff who complete consents on the importance of offering a copy of the consent to the client by August 15, 2023. All employees who complete consents will be required to sign stating they understand the importance of offering the client a copy of the consent and documenting the client was offered.
New employees will be educated on this policy during new employee orientation starting August 2023. A review for all staff will occur during the yearly annual mandatory training.
Signature pages will be kept in the employee's file. CEO will ensure compliance.
Client #2 and client #8 are no longer in treatment and consent is unable to be redone.
The quality director will review 10 client records per month for the next 3 months to ensure documentation showing the consent was offered to the client. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to develop a data collection system that allows for the efficient retrieval of data needed to measure the project's performance at the time of the inspection.
The facility was unable to produce client records in an efficient manner after the DDAP representatives requested them. On June 7, 2023, the DDAP representatives requested specific client records from a list of active and discharged clients provided by the facility. It took over two hours for the facility to provide the client records from the active list and the facility did not provide the client records from the discharged list until June 9, 2023. Additionally, the list of " active" clients included several clients who were discharged in the days and weeks prior to the inspection date.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
For ongoing inspections, the CFO will print a list of current clients and a list of discharged clients from the billing system to ensure accuracy.
The electronic medical record will be fully implemented by September 30, 2023. Implementation will make all client records electronic for ease of review.
CEO will coordinate with Acadia IT to complete the EMR project.
A senior member of the division team will be present at the next inspection to aid with retrieval of information.
The division president and/or regional vice president will meet and/or conference call with the CEO weekly for the next 3 months to review survey readiness. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event involving the physical or sexual assault by staff or a client.
On September 21, 2022, September 22, 2022, October 9, 2022, October 18, 2022, January 9, 2023, and April 10, 2023, there were physical altercations at the facility; however, there was no documentation that these unusual incidents were reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The quality director will complete the unusual incident reports for the physical altercations that occurred on the designated dates in the deficiency and turn them in by August 12, 2023.
The quality manager/designee (in her absence) has been trained on unusual incident reports and will complete an unusual incident report and turn it in within 3 business days of an assault occurring.
The CEO will complete random audits of unusual incident reports after assaults occur over the next 4 months to ensure timely completion and submission to the department. |
709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in three of three applicable client records reviewed.
Client #1 was admitted to the inpatient non-hospital detoxification activity on May 6, 2023 and left against medical advice on May 7, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.
Client #2 was admitted to the inpatient non-hospital detoxification activity on May 8, 2023 and left against medical advice on May 12, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.
Client #7 was admitted to the inpatient non-hospital detoxification activity on May 7, 2023 and left against medical advice on May 14, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The case management team have been re-educated on the importance of doing a 7 day follow up on all clients regardless of where they are going upon discharge from treatment. Follow up will occur even when clients decline aftercare in an effort to see if the client is in need of treatment/recommendations at that time.
The Clinical Director will ensure compliance.
The Clinical Director will audit 10 charts for the next 3 months to ensure compliance and report findings to the CEO and Quality Director.
Clients #1, #2 and #7 will be contacted by July 31, 2023 to see if they are in need of services at this time.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to provide documentation that the narcotic treatment physician conducted the initial face-to-face determination with the client prior to the administration of agent in one of eleven applicable patient records reviewed.
Patient #2 was admitted to the inpatient non-hospital detoxification activity on May 8, 2023 and was discharged on May 12, 2023. The physician prescribed the patient's first dose of medication on May 8, 2023; however, the initial face-to-face meeting with the physician was conducted and documented on May 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will meet with the Medical Director to discuss the importance of the narcotic treatment physician making a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Documentation of the face-to-face determination will be recorded in the patient record.
The DON will review 10 charts for the next 3 months to ensure compliance.
Client #2 is no longer in treatment and consent is unable to be redone.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent form before an agent may be administered to the patient for either maintenance of detoxification treatment in one of eleven applicable patient records reviewed.
Patient #2 was admitted to the inpatient non-hospital detoxification activity on May 8, 2023 and was discharged on May 12, 2023. The physician prescribed the patient's first dose of medication on May 8, 2023; however, the consent to treatment with an agent was signed and dated by the patient on May 9, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will meet with the Medical Director to discuss the importance of obtaining an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The consent will include the following: methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision; methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results; alternative methods of treatment exist; possible risks and complications of treatment have been explained to the patient; methadone is transmitted to the unborn child and will cause physical dependence.
An informed, voluntary written consent will be in the client record prior to administering a narcotic.
The DON will review 10 charts for the next 3 months to ensure compliance.
Client #2 is no longer in treatment and consent is unable to be redone.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in one of eleven patient records reviewed.
Patient #11 was admitted to the inpatient non-hospital activity on January 18, 2023 and was discharged on March 10, 2023. There was no documented drug-screen urinalysis for the month of February 2023, in the record, at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will meet with the Medical Director to discuss the importance of completing an initial drug-screening urinalysis for each prospective patient and random urinalysis at least monthly thereafter.
Drug screen results will be stored in the EMR.
The DON will review 10 charts for the next 3 months to ensure completion.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment, 1 hour of which shall be individual psychotherapy, in one of one applicable patient records reviewed.
Patient #11 was admitted to the inpatient non-hospital activity on January 18, 2023 and was discharged on March 10, 2023. The record of service and progress notes documented that for the month of February 2023, the patient received 2.5 hours of group psychotherapy and 0 hours of individual psychotherapy.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will meet with the Medical Director to discuss the importance of providing individualized psychotherapy services and meet the requirements of providing each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy and providing additional psychotherapy as dictated by an ongoing assessment of the patient.
Psychotherapy services will be documented in the client record.
The DON will review 10 charts for the next 3 months to ensure completion.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in three of three applicable patient records reviewed.
Patient #3 was admitted to the inpatient non-hospital detoxification activity on May 2, 2023 and was discharged on May 9, 2023. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #4 was admitted to the inpatient non-hospital detoxification activity on January 26, 2023 and was discharged on January 28, 2023. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #11 was admitted to the inpatient non-hospital activity on January 18, 2023 and was discharged on March 10, 2023. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing will reeducate the dosing nurses on the MAT transfer protocol. All dosing nurses will sign off that they have no questions about the process.
The MAT transfer sheet, that includes date of admit to BGB and first dose needs to be completed on all clients coming in on MAT. The transfer sheet needs to be faxed to the old clinic to notify them that the client admitted and what dose they started on at Bowling Green. The transfer sheet then needs to be filed in the chart.
The director of nursing will audit 10 charts a week for the next 12 weeks to ensure compliance.
Patients #3,4 and 11 were discharged and no longer in treatment therefore consents cannot be obtained to notify their previous program. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 document that an individual treatment and rehabilitation plan was developed with the client in three of seven client records reviewed.
Client #12 was admitted to the inpatient non-hospital activity on January 28, 2023 and was discharged on March 12, 2023. There was no individual treatment and rehabilitation plan developed with the client prior to discharge.
Client #13 was admitted to the inpatient non-hospital activity on February 10, 2023 and was discharged on February 15, 2023. There was no individual treatment and rehabilitation plan developed with the client prior to discharge.
Client #14 was admitted to the inpatient non-hospital activity on February 1, 2023 and was discharged on February 28, 2023. The individual treatment and rehabilitation plan was completed on February 2, 2023; however, there was no documentation the plan was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and Regional VP re-educated clinical staff on the importance of completing the treatment plan(s) within the designated time frames. This training occurred on June 21, 2023.
If a clinical team member is unable to complete the treatment plan within the designated time frame, he/she will notify his/her clinical supervisor so arrangements can be made for timely completion.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure treatment plans are completed timely.
Clinical supervisors will ensure compliance.
Clients #12, #13 and #14 are no longer in treatment and consent is unable to be redone.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 document the type and frequency of treatment and rehabilitation services on the client's individual treatment plan in two of five applicable client records reviewed.
Client #10 was admitted to the inpatient non-hospital activity on May 9, 2023 and was discharged on May 23, 2023. The individual treatment and rehabilitation plan, completed on May 10, 2023, did not include the type and frequency of treatment and rehabilitation services.
Client #14 was admitted to the inpatient non-hospital activity on February 1, 2023 and was discharged on February 28, 2023. The individual treatment and rehabilitation plan, completed on February 2, 2023, did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and Regional VP will re-educate clinical staff on the importance of documenting the type and frequency of treatment and rehabilitative services on the treatment plan. This training occurred on June 21, 2023.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure documentation of type and frequency of treatment. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
Clients #10 and #14 are no longer in treatment and consent is unable to be redone.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to assure that treatment and rehabilitation plans were reviewed and updated at least every 15 days for client treatment regime that is less than 30 days in three of five applicable client records reviewed.
Client #9 was admitted to the inpatient non-hospital activity on May 6, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 6, 2023, and the first treatment plan update was due no later than May 21, 2023; however, the update was not completed at the time of inspection.
Client #11 was admitted to the inpatient non-hospital activity on January 18, 2023 and was discharged on March 10, 2023. The individual treatment and rehabilitation plan was completed on January 26, 2023, and the first treatment plan update was due no later than February 10, 2023; however, the update was not completed prior to discharge.
Client #14 was admitted to the inpatient non-hospital activity on February 1, 2023 and was discharged on February 28, 2023. The individual treatment and rehabilitation plan was completed on February 2, 2023, and the first treatment plan update was due no later than February 17, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and Regional VP will re-educate clinical staff on the importance of completing the treatment plan update within the designated time frames. This training occurred on June 21, 2023.
If a clinical team member is unable to complete the treatment plan update within the designated time frame, he/she will notify his/her clinical supervisor so arrangements can be made for timely completion.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure treatment plan updates are completed timely. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
Clients #9, #11 and #14 are no longer in treatment and consent is unable to be redone.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of three applicable client records reviewed.
Client #9 was admitted to the inpatient non-hospital activity on May 6, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan completed on May 6, 2023, specified 1-2 individual sessions per week. There was no documentation, in the record, of individual counseling sessions occurring throughout the treatment episode.
Client #11 was admitted to the inpatient non-hospital activity on January 18, 2023 and was discharged on March 10, 2023. The individual treatment and rehabilitation plan completed on February 26, 2023, specified 1-2 individual counseling sessions per week. There was no documentation, in the record, of individual counseling sessions occurring during the weeks of February 5, 2023 through discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director will re-educate clinical staff on the importance of assuring counseling services are provided according to the individual treatment and rehabilitation plan.
The clinical supervisors will monitor 10 charts for the next 3 months to ensure counseling services are provided according to the individual treatment and rehabilitation plan. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
Clients #9 and #11 are no longer in treatment and consent is unable to be redone.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information in five of five applicable client records reviewed.
Client #10 was admitted to the inpatient non-hospital activity on May 9, 2023 and was discharged on May 23, 2023. There was no follow-up information, in the record, at the time of inspection.
Client #11 was admitted to the inpatient non-hospital activity on January 18, 2023 and was discharged on March 10, 2023. There was no follow-up information, in the record, at the time of inspection.
Client #12 was admitted to the inpatient non-hospital activity on January 28, 2023 and was discharged on March 12, 2023. There was no follow-up information, in the record, at the time of inspection.
Client #13 was admitted to the inpatient non-hospital activity on February 10, 2023 and was discharged on February 15, 2023. There was no follow-up information, in the record, at the time of inspection.
Client #14 was admitted to the inpatient non-hospital activity on February 1, 2023 and was discharged on February 28, 2023. There was no follow-up information, in the record, at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The case management team will be re-educated on the importance of doing a 7 day follow up on all clients regardless of where they are going upon discharge from treatment. Follow up will occur even when clients decline aftercare in an effort to see if the client is in need of treatment/recommendations at that time.
The clinical director will ensure compliance.
The clinical director will audit 10 charts for the next 3 months to ensure compliance and report findings to the CEO and Quality Director.
Clients #10, #11, #12, #13 and #14 will be contacted by July 31, 2023 to see if they are in need of services at this time.
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