INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2024 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 LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to develop and implement a mechanism to collect feedback on all completed trainings.
The facility's policy and procedure stated employees who attend training sessions paid for by PA facility locations are required to complete a training feedback form and submit it to the QI/Staff development department along with a copy of their training certificates.
The facility was unable to provide training feedback forms for every applicable personnel trainings reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Manager and HR Director will review the policy/procedure manual and personnel records to develop and document a mechanism to collect feedback on all completed trainings July 15, 2024. The HR Director will maintain once mechanism is established. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of one applicable personnel record reviewed.
Employee #4 was hired as a clinical supervisor/counselor on March 18, 2024. The emergency preparedness training was not provided and documented as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Plant Operations will train all new hires during orientation regarding all staff to perform assigned tasks during emergencies, all new hires will sign the signature page and they will be forwarded to their supervisor for additional signature and place in personal file by July 15, 2024.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to maintain the confidentiality of client identity and their records in one of nine client records reviewed.
Client #6 was admitted on February 14, 2024 and discharged on March 13, 2024. During the review of the record, there was another client's intake and orientation documents included in this client's record.
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 paying attention to detail. The counselor will practice confirming the identity the client's records by date of birth and admission date by 7/15/2024 to avoid HIPPA violations. The clinical supervisors will monitor 10 charts for the next 3 months to ensure client records are accurate. These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance.
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709.83(a)(11) LICENSURE Client records
709.83. 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 three applicable client records reviewed.
Client #6 was admitted on February 14, 2024 and was discharged on March 13, 2024. There was no follow-up information in the record at the time of the inspection.
Client #7 was admitted on February 16, 2024 and was discharged on March 4, 2024. There was no follow-up information in the record at the time of the inspection.
Client #8 was admitted on February 23, 2024 and was discharged on April 9, 2024. There was no follow-up information in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will Facilitate follow up information training with Referral Coordinator to ensure documentation is in the record by July 15, 2024.
The Clinical Supervisor will audit all discharges weekly to ensure compliance by July 15, 2024 |