INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7 through June 9, 2010 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 and a plan of correction is due on July 7, 2010.
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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 that each counselor met the qualifications for the position in four of five records, as required.
Findings:
Twenty-four personnel records were reviewed on June 7 and June 8, 2010. Five records were reviewed for qualifications of counselor. Four out of five records lacked the requirements for counselor.
In personnel record #5, the counselor did not meet the qualifications for the position of counselor based on the lack of clinical experience. Employee # 5 was hired on 4/5/2010. and has a BS in Criminal Justice; however, the employee's resume was reviewed for work experience and they failed to have one year clinical experience in a health or human service agency, preferably in a drug and alcohol setting.
In personnel record # 10, the counselor did not meet the qualifications for the position of counselor based on the lack of clinical experience. Employee # 10 was hired 9/15/2009 and has a BA in Psychology. A review of the employee's resume revealed that at the time of hire the employee did not have any clinical experience in a health or human service agency, preferably in a drug and alcohol setting.
In personnel record # 11, the employee was hired on 9/21/2009 as a counselor. Employee # 11's resume was reviewed for qualifications of a counselor. At the time of hire, the employee did not have a degree in a related field. The employee did not receive their degree until December 2009. The facility failed to place the employee in the correct position. The employee should have been a counselor assistant for the first three months of employment until they received their degree in a related field.
In personnel record # 12, the employee was hired on 3/9/2010 as a counselor. The employee did not meet the qualifications of counselor based on a degree Environmental Science. A review of the Environmental Science curriculum was reviewed by the Division and were found not to meet the educational component for the position of counselor.
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Plan of Correction
Four out of the five counselors qualify for Counselor Assistant positions and one qualifies for a high school level Counselor Assistant. They were transferred into these positions effective 6/13/2010. Facility is now in compliance with cited standard. Supervision and reviews will be completed as required by state standards.
All new hires and transfers will be reviewed and approved by direct supervisor as well as reviewed by Human Resources to insure applicant / employee holds correct credentials required of new position. This will occur before applicant / employee begins employment or is transferred into a new position.
Ongoing compliance will be maintained by Clinical Supervisor with review and approval by Human Resources. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records and an interview with the clinical supervisor it was confirmed that the facility failed to demonstrate that performance evaluations were conducted semi-annually for counselor assistants.
The findings were:
Employee record # 6 is a counselor assistant. The record contained documented performance evaluations for July 18, 2008 and July 22, 2009. An interview with the clinical supervisor on June 7, 2010 confirmed that no performance evaluation was conducted semi-annually for Employee # 6.
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Plan of Correction
Clinical Director will work with the HR Director and will put in the clinical supervision binder when reviews are to be completed and work with HR to maintain compliance.
Every 6 months, after date of hire a performance evaluation will be completed by the Clinical Director and the HR Director will maintain this record in the personnel file
Monthly monitor 90, 180 and annual evaluations
Maintainence of compliance will be done by Clinical Director and HR Director. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of agency policy and procedure manual,staffing requirements facility summary report, an interview with the facility director, and staff training files the facility did not comply with this regulation.
The findings include:
Based on a review of agency policy and procedure manual,staffing requirements facility summary report, an interview with the facility director on June 7, 2010, the facility failed to document staff training needs assessments. According to the policy and procedure manual the needs assessment form will be completed jointly by the supervisor and employee upon hire and annually thereafter. The facility's training year is January through December. The facility failed to document training plans for 89 out of 104 employees for the 2010 training year.
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Plan of Correction
Training Needs Assessment and will be completed by 7/15/10.
Training Needs Assessments have been distributed and will be completed jointly by the by the supervisor and employee for the training year 2010.
Human Resource and supervisors will ensure that individual training plans are completed upon hire and annually.
Human Resources and supervisors will be responsible for ongoing compliance via random HR/Training file audits. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative materials and an interview with the facility director the facility failed to complete an overall training plan.
The findings include:
The administrative manual was reviewed on June 7, 2010. The facility failed to provide an overall plan for addressing staff training needs for the 2010 training year. An interview with the facility director on 6/7/2010 at 11:15 a.m. confirmed that this was not complete.
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Plan of Correction
2010 Overall Training Plan will be completed by 8/1/10 by Human Resources Coordinator.
Overall Training Plan will be completed annually by Human Resource Coordinator.
Human Resource Coordinator will be responsible for ongoing compliance. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative materials and an interview with the facility director the facility failed to complete an annual evaluation of the overall training plan.
The findings include:
The administrative manual was reviewed on June 7, 2010. The facility failed to provide an annual evaluation of the overall plan for addressing staff training for the 20009 training year. An interview with the facility director on 6/7/2010 at 11:15 a.m. confirmed that this was not complete.
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Plan of Correction
Evaluation of overall training plan will be completed by 8/1/10 by Human Resource Coordinator.
Evaluation of overall training plan will be completed annually by Human Resource Coordinator.
Human Resource Coordinator will be responsible for ongoing compliance. |
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 the facility staffing requirements facility summary report , personnel records and an interview with the facility director, the facility failed to provide documentation of individual training plans in 88 out of 104 personnel records.
The findings include:
The facility staffing requirements summary report and personnel records were reviewed on June 7, 2010. Individual training plans were required in 104 personnel records. The facility did not document individual training plans for the January 1 - December 31, 2010 training year in 88 records according to the staffing requirements summary report. An interview with the facility director at 11:15 a.m. on June 7, 2010 confirmed that the training plans for 2010 were not completed on staff except for new hires.
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Plan of Correction
Individual Training Plans will be completed by 7/15/10 - jointly completed by the supervisor and employee for the training year 2010.
Human Resource Coordinator and supervisors will ensure that individual training plans are completed upon hire and annually.
Human Resources and supervisors will be responsible for ongoing compliance. |
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 staffing requirements summary report, personnel training records and an interview with the facility director, the facility failed to provide documentation of TB/STD training in nine out of twenty-four personnel training records, as required by regulation. Also, ten out of twenty-four personnel failed to have HIV/AIDS training.
The findings include:
Ten personnel training records and the facility staffing requirement summary report were reviewed on June 7, 2010. Twenty-four personnel were required to have documentation of TB/STD training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel training records # 15, 16, 18, 19, 20, 21, 22, 23, 24. The facility did not provide H IV/AIDS training in personnel training records # 9, 15, 16, 17, 18, 19, 20, 21, 22, and 23.
Employee # 9 is a counselor assistant and was hired on 9/15/2008. TB/STD and HIV/AIDS training was due to be completed no later than 9/15/2009. The facility failed to provide documentation of HIV/AIDS training. Also, the facility failed to ensure that the TB/STD training was completed within one year of hire per the standard. The employee did not receive the TB/STD training until 1/26/2010 which was over four months late.
Employee # 15 is support staff and was hired 3/22/2007. TB/STD and HIV/AIDS training was due to be completed no later than 3/22/2009. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 16 is support staff and was hired 6/12/2006. TB/STD and HIV/AIDS training was due to be completed no later than 6/12/2008. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 17 is support staff and was hired 10/5/2006. HIV/AIDS training was due to be completed no later than 10/5/2008. The facility failed to provide documentation of HIV/AIDS training.
Employee # 18 is support staff and was hired 2/5/2008. TB/STD and HIV/AIDS training was due to be completed no later than 2/5/2010. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 19 is support staff and was hired 4/30/2007. TB/STD and HIV/AIDS training was due to be completed no later than 4/30/2009. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 20 is support staff and was hired 4/25/2007. TB/STD and HIV/AIDS training was due to be completed no later than 4/25/2009. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 21 is support staff and was hired 10/12/2007. TB/STD and HIV/AIDS training was due to be completed no later than 10/12/2009. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 22 is support staff and was hired 2/19/2008. TB/STD and HIV/AIDS training was due to be completed no later than 2/19/2010. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 23 is support staff and was hired 6/9/2008. TB/STD and HIV/AIDS training was due to be completed no later than 6/9/2010. The facility failed to provide documentation of TB/STD and HIV/AIDS training.
Employee # 24 is support staff and was hired 6/20/2007. TB/STD training was due to be completed no later than 6/20/2009. The facility failed to provide documentation of TB/STD training.
The facility director was interviewed on March 30, 2010 at approximately 11:00 AM and confirmed that these employees had not completed TB/STD training. The facility director reported these employees are scheduled to complete TB/STD training on April 28, 2010.
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Plan of Correction
Mandatory Communicable Disease Training will be completed for all non-compliant staff by 8/26/2010. In-house trainer with the utilization of DAPL curriculum will be utilized to achieve compliance.
All staff will be scheduled for training by supervisors within the first year of training for counselor and counselor assistants and the first two years of training for all other staff.
Human Resources and supervisors will be responsible for ongoing compliance. This will be audited via random HR/Training file audits.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in three of three records reviewed.
The findings include:
Twelve client records were reviewed on June 2 and June 3, 2010. Three of the records were from the partial hospitalization program. The psychosocial evaluations were not evaluative in client record # 10, 11, and 12.
In client record # 10 the psychosocial evaluation had inconsistent information in the composite picture. The client's problems/needs, assets/strengths, and support systems were not evaluative.
In client record # 11 the client's assets/strengths were not evaluative.
In client record # 12 the client's problems/needs and assets/strengths were not evaluative. The clinical also failed to address the client's coping mechanisms.
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Plan of Correction
Clinical Director will, during weekly chart audits, monitor the diagnostic summary for compliance with the regulations. During this audit it will be assessed that the summary is truly being used as a summative evaluation and not just a regurgitation of information.
Weekly monitoring of a sampling of charts from each clinician, documenting on the audit tool, and using this as part of supervision and training, will be done. Clinical Director will be responsible for maintaining compliance |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the 2009 annual report and an interview with the facility director, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders, as required by regulation.
The findings include:
The 2009 annual report was reviewed on June 7, 2010. The facility is publicly funded and required by regulation to make available to the public an annual report which includes a statement disclosing the names of officers, directors and principal shareholders. On March 11, 2010, the facility made available to the public the 2009 annual report. The 2009 annual report did not include a statement disclosing the names of officers, directors and principal shareholders .
On June 2, 2010 at approximately 11:30 AM the facility director was interviewed. The facility director confirmed that a statement disclosing the names of officers, directors and principal shareholders had not been included in the annual report.
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Plan of Correction
List of officers, director and principal shareholders was inserted into the Annual Report on 6/10/2010.
A list of mandatory information to be included in the annual report will be used as an audit tool for future annual reports.
Facility Director is repsonsibel to assure this is part of the annual report on an annual basis.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of the policy and procedure manual on June 7 and June 8, 2010 and a review of client records on June 9, 2010, the facility failed to document a psychosocial evaluation in two of three client records reviewed.
Findings:
Twelve client records were reviewed on June 8 and 9, 2010. Three clients were from the inpatient non-hospital detoxification program. Two of the three detoxification records required a psychosocial evaluation. Based on a review of client records the facility failed to complete a psychosocial evaluation in client records # 7 and 8.
According to the facility policy and procedure manual , 709.51 Intake and Admission (Detox), page 6, VII. states, " Within 72 hours, clients shall meet with staff to complete a psychosocial assessment. The facility failed to follow their policy.
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Plan of Correction
The Nursing Assessment will be ammended to include an area for a psychosocial evaluation to be done by the Nursing Staff upon admission. This will serve as the psychosocial evaluation in the event that the patient does not enter into the rehabilitation program.
This form will be ammended, staff trained, with full implementation by 8/1/2010.
Daily chart checks by delegated staff and random chart audits by the DON will assure ongonig complianc with this standard.
DON is responsible to assure ongoing compliance. |
709.63(a)(7) LICENSURE Discharge summary
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(7) Discharge summary.
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Observations
Based on the review of client records and an interview with the clinical supervisor, the facility failed to document a discharge summary.
The findings include:
On June 8 and 9, 2010 twelve client records were reviewed. Three client records were from the inpatient non-hospital detoxification program. One of three records required a discharge summary. The facility failed to document a discharge summary in client record # 9.
Client # 9 was admitted into treatment on 5/21/2010 and discharged on 5/22/2010. As of the date of the inspection a discharge summary was not completed for this client. An interview with the clinical director confirmed that there was not a discharge summary for this record.
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Plan of Correction
A Detox Discharge summary form will be created, staff trained, with full implementation by 8/1/2010 that will assign nursing or medical staff to complete a discharge summary within 7 days of a patient discharging out of the Detox Level of Care.
Daily chart checks by delegated staff and random chart checks by the DON will assure compliance.
DON responsible for ongoing compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records , the facility failed to document a complete psychosocial evaluation in six of six records reviewed.
The findings include:
Twelve client records were reviewed on June 2 and June 3, 2010. Six of the records were from the inpatient non-hospital program. The psychosocial evaluations were not evaluative in client record # 1, 2, 3, 4, 5, and 6.
In client record # 1 the psychosocial evaluation failed to document an evaluation of the client's problems and needs, assets and strengths, support systems, and negative factors that may inhibit treatment. Additionally, the evaluation did not address the client's coping mechanisms.
In client record # 2 the psychosocial evaluation failed to document an evaluation of the client's assets and strengths.
In client record # 3 the psychosocial evaluation failed to document an evaluation of the client's problems and needs, assets and strengths, and negative factors that may inhibit treatment.
In client record # 4 the psychosocial evaluation failed to document an evaluation of the client's assets and strengths. Additionally, the evaluation did not address the client's support systems.
In client record # 5 the psychosocial evaluation failed to document an evaluation of the client's problems and needs, assets and strengths, and negative factors that may inhibit treatment. Additionally, the evaluation did not address the client's support systems
In client record # 6 the psychosocial evaluation failed to document an evaluation of the client's assets and strengths and support systems. Additionally, the evaluation did not address the client's coping mechanisms.
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Plan of Correction
Clinical Director will, during weekly chart audits, monitor the diagnostic summary for compliance with the regulations. During this audit it will be assessed that the summary is truly being used as a summative evaluation and not just a regurgitation of information. Weekly monitoring of a sampling of charts from each clinician, documenting on the audit tool, and using this as part of supervision and training, will be done. Clinical Director will be responsible for maintaining compliance |