INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on December 11, 2023 through December 12, 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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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 one of one 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 # 11 was admitted to the inpatient non-hospital rehabilitation activity on October 7, 2023 and left against medical advice on October 11, 2023. There was no documentation, in the record, that the facility contacted the emergency contact within 12 hours at the time of the inspection.
This is a repeat citation from the June 9, 2023 annual licensing 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 December 31, 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 the EC within 12 hours when an individual leaves against medical advice. This re-education will be completed by January 15, 2024.
New employees will be educated on this policy during new employee orientation starting January 2024. 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 by reviewing outcome in the weekly POC meeting.
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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 December 11, 2023, there were unsecured client records in the mansion's room # 9 and in the barn's room #5.
This is a repeat citation from the June 9, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-educated on the importance of storing charts or identifiable PHI in the designated chart room, which has two locks. The signature sheet signed will acknowledge that staff understands the expectation. This re-education will be completed by January 15, 2024.
Quality Manger will ensure compliance by conducting weekly leadership rounds.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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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 at the facility requiring the presence of police, fire, or ambulance personnel.
There were incidents that required the presence of police, fire, or ambulance personnel at the facility on July 1, 2023, July 2, 2023, July 28, 2023, July 30, 2023, August 28, 2023, August 30, 2023, September 8, 2023, September 16, 2023, September 17, 2023, September 28, 2023, October 5, 2023, October 20, 2023, October 21, 2023, October 27, 2023, October 28, 2023, November 2, 2023, November 8, 2023, November 11, 2023, November 12, 2023, November 15, 2023 and November 17, 2023; however, none of the incidents were reported to the Department within 3 business days of occurring.
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 importance of submitting unusual incident reports that require police, fire and ambulances on campus within 24-48 hours of incident. Leadership will identify an additional member to submit incident reports in the Quality Manager absence by January 1, 2024
Quality Manger will ensure compliance. |
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 and a discussion with facility staff, the narcotic treatment program failed to ensure that the narcotic treatment physician conducted the initial face-to-face determination with the client prior to the administration of an agent in four of ten applicable patient records reviewed.
Patient # 2 was admitted to the inpatient non-hospital detoxification activity on December 8, 2023 and was still active at the time of the inspection. The patient was prescribed methadone; however, in the record, there was a printout of a picture of the physician's face to face determination of dependency, dated December 9, 2023. The medical director advised the DDAP representatives that the documentation was a picture, and not the original document, because on weekends the physician makes the dependency determination via telehealth, not in-person.
Patient # 3 was admitted to the inpatient non-hospital detoxification activity on December 8, 2023 and was still active at the time of the inspection. The patient was prescribed methadone; however, in the record, there was a printout of a picture of the physician's face to face determination of dependency, dated December 9, 2023. The medical director advised the DDAP representatives that the documentation was a picture, and not the original document, because on weekends the physician makes the dependency determination via telehealth, not in-person.
Patient # 6 was admitted to the inpatient non-hospital detoxification activity on October 9, 2023 and was discharged on October 14, 2023. The patient was prescribed methadone; however, in the record, there was a printout of a picture of the physician's face to face determination of dependency, dated October 10, 2023. The medical director advised the DDAP representatives that the documentation was a picture, and not the original document, because on weekends the physician makes the dependency determination via telehealth, not in-person.
Patient # 12 was admitted to the inpatient non-hospital detoxification activity on October 15, 2023 and was still active at the time of the inspection. The patient was prescribed methadone; however, in the record, there was a printout of a picture of the physician's face to face determination of dependency, dated October 10. The medical director advised the DDAP representatives that the documentation was a picture, and not the original document, because on weekends the physician makes the dependency determination via telehealth, not in-person.
This is a repeat citation from the June 9, 2023 annual licensing inspection.
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 by 12/31/2023
The DON will review 5 charts weekly for the next 3 months to ensure compliance. |
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 narcotic treatment program 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 two of two applicable patient records reviewed.
Client # 10 was admitted to the inpatient non-hospital activity on July 12, 2023 and was discharged on September 1, 2023. The record of service and progress notes for the month of August 2023 documented the patient received over 2.5 hours of group psychotherapy; however, there were 0 hours of individual psychotherapy.
Patient # 12 was admitted to the inpatient non-hospital detoxification activity on October 15, 2023 and was still active at the time of the inspection. The record of service and progress notes for the month of November 2023 documented the patient received over 2.5 hours of group psychotherapy; however, there were 0 hours of individual psychotherapy.
This is a repeat citation from the June 9, 2023 annual licensing 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 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 5 charts weekly 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 two of two applicable patient records reviewed.
Patient # 2 was admitted to the inpatient non-hospital detoxification activity on December 8, 2023 and was still active at the time of the inspection. 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 # 6 was admitted to the inpatient non-hospital detoxification activity on October 9, 2023 and was discharged on October 14, 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.
This is a repeat citation from the June 9, 2023 annual licensing inspection.
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 providing a written transfer/notification for Clients referred for to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 24hours of admission.
The Doctor will meet with the client within 24hrs of admission. The Nurse will contact the referring narcotic treatment program on the date of admission.
The methadone/subutex check list was revised to show documentation to where the dosing nurse is placing a call to the clinic. The complete transition letter will be uploaded into the EMR.
The Nurse Manager will conduct weekly audits of 10 charts to ensure compliance and review in the weekly POC meeting.
This will include efficient documentation of transfer and acceptance by 12/31/23 |
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 three of six applicable client records reviewed.
Client # 10 was admitted to the inpatient non-hospital activity on July 12, 2023 and was discharged on September 1, 2023. The individual treatment and rehabilitation plan, completed on August 17, 2023, did not include the type and frequency of treatment and rehabilitation services.
Client # 14 was admitted to the inpatient non-hospital activity on August 28, 2023 and was discharged on September 30, 2023. The individual treatment and rehabilitation plan, completed on September 6, 2023, did not include the type and frequency of treatment and rehabilitation services.
Client # 15 was admitted to the inpatient non-hospital activity on August 8, 2023 and was discharged on August 30, 2023. The individual treatment and rehabilitation plan, completed on August 10, 2023, did not include the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the June 9, 2023 annual licensing inspection.
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 documenting the type and frequency of treatment and rehabilitative services on the treatment plan by January 1, 2024. Previous training occurred on June 21, 2023.
The clinical supervisors will continue to monitor 5 charts weekly for the next 3 months to ensure documentation of type and frequency of treatment. These audits will continue be turned into the Quality Manager. Clinical Director will review weekly during case consultation with the clinical team to ensure compliance and at the weekly POC meeting. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days for a client treatment regime that is less than 30 days in two of four applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on September 13, 2023 and was discharged on October 9, 2023. The individual treatment and rehabilitation plan was completed on September 13, 2023, and the first treatment plan update was due no later than September 28, 2023; however, the update was not completed prior to discharge.
Client # 15 was admitted to the inpatient non-hospital activity on August 8, 2023 and was discharged on August 30, 2023. The individual treatment and rehabilitation plan was completed on August 10, 2023, and the first treatment plan update was due no later than August 25, 2023; however, the update was not completed prior to discharge.
This is a repeat citation from the June 9, 2023 annual licensing inspection.
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 completing the treatment plan update within the designated time frames by January 1, 2024. Previous training occurred on June 21, 2023. The signature sheet signed will acknowledge that staff understands the expectation.
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 5 charts weekly 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 by reporting findings in the POC meeting and holding staff accountable.
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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 three of five applicable client records reviewed.
Client # 9 was admitted to the inpatient non-hospital activity on September 13, 2023 and was discharged on October 9, 2023. There was no follow-up information in the record at the time of inspection.
Client # 10 was admitted to the inpatient non-hospital activity on July 12, 2023 and was discharged on September 1, 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 August 28, 2023 and was discharged on September 30, 2023. There was no follow-up information in the record at the time of inspection.
Client # 15 was admitted to the inpatient non-hospital activity on August 8, 2023 and was discharged on August 30, 2023. There was no follow-up information in the record at the time of inspection.
This is a repeat citation from the June 9, 2023 annual licensing 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 signature sheet signed will acknowledge that staff understands the expectation. The re-education was completed on January 19, 2023
The clinical director will ensure compliance by auditing 5 charts weekly for the next 3 months to ensure compliance and report findings to the CEO and Quality Director during the weekly POC meeting. The clinical director will hold the staff accountable.
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