INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection, and inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine in the treatment of narcotic addiction. This inspection was conducted on June 20-22, 2016 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:
|
Plan of Correction
|
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.
|
Observations
Twenty-four personnel records were reviewed on June 20-22, 2016. The facility did not provide documentation of the required 6 hours HIV/AIDS and 4 hours TB/STD training in eight of twenty-four personnel records reviewed.
Employee # 17, an admissions coordinator, was hired November 21, 2013. The facility failed to ensure employee # 17 completed HIV/AIDS training by November 21, 2015.
Employee #18, a clinical technician, was hired September 4, 2013. The facility failed to ensure employee #18 completed HIV/AIDS and TB/STD training by September 4, 2015.
Employee #19, a clinical technician, was hired July 13, 2013. The facility failed to ensure employee #19 completed HIV/AIDS and TB/STD training by July 13, 2015.
Employee #20, a patient accounts rep, was hired July 30, 2013. The facility failed to ensure employee #20 completed HIV/AIDS training by July 30, 2015.
Employee #21, an admissions coordinator, was hired March 1, 2013. The facility failed to ensure employee #21 completed HIV/AIDS and TB/STD training by March 1, 2015.
Employee #22, a receptionist, was hired April 17, 2013. The facility failed to ensure that employee #22 completed HIV/AIDS and TB/STD training by April 17, 2015.
Employee #23, office manager, was hired November 4, 2013. The facility failed to ensure that employee #23 completed HIV/AIDS and TB/STD training by November 4, 2015.
Employee #24, a counselor, was hired January 28, 2015. The facility failed to ensure that employee #24 completed HIV/AIDS and TB/STD training by January 28, 2016.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the June 11, 2015 Licensing inspection.
|
Plan of Correction
As of June 17 all but one of the eight identified employees have taken both HIV/AIDS and TB/STD trainings.
Employee #19 will be scheduled to take HIV on 9/7/16 and TB/STD on 9/9/16.
Furthermore, three nursing staff have been trained to present these trainings on-site. Both HIV/AIDS and TB/STD will be held on-site at Bowling Green every six months.
QM will track hire dates and schedule employees for these trainings within the required time frames. |
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.
|
Observations
Based on a review of client records on June 20-21, 2016, the facility failed to obtain an informed and voluntary consent in ten of twenty-three client records. The "Authorization for Release of Information" form did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility's "Authorization for Release of Information" form documented, "I may revoke this authorization at any time. Revocations to this authorization must be presented in writing."
Client #4 was admitted on January 4, 2016 and was discharged on January 9, 2016. An undated consent to the funding source failed to comply with 42 CFR as the consent only allowed the client to revoke their consent form in writing.
Client #6 was admitted on April 30, 2016 and was discharged on May 5, 2016. A consent dated 4/30/2016 to the funding source failed to comply with 42 CFR as the consent only allowed the client to revoke their consent form in writing.
Client #7 was admitted on May 9, 2016 and was discharged May 22, 2016. A consent dated 5/9/2016 to the funding source failed to comply with 42 CFR as the consent only allowed the client to revoke their consent form in writing.
Client #11 was admitted on April 5, 2016 and was discharged April 10, 2016. Consents dated 4/5/2016 to the funding source and a pharmacy failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #12 was admitted on April 8, 2016 and was discharged April 19, 2016. Consents dated 4/8/2016 to the funding source, referral source, employer and pharmacy failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #13 was admitted February 9, 2016 and was discharged March 10, 2016. Consents dated 2/9/2016 to the funding source, pharmacy and primary care physician failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #14 was admitted January 18, 2016 and was discharged February 13, 2016. Consents dated 1/18/2016 to the funding source and primary care physician failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #15 was admitted December 4, 2015 and was discharged January 1, 2016. Consents dated 12/4/2015 to the funding source, employer, and primary care physician failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #22 was admitted April 7, 2016 and was discharged April 12, 2016. Consents dated 4/7/2016 to the funding source and a government agency failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
Client #23 was admitted February 10, 2016 and was discharged March 7, 2016. Consents dated to the funding source, pharmacy, government agency failed to comply with 42 CFR as the consent only allowed the client to revoke their consent forms in writing.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Our Release of Information forms were revised and put in to use on May 16, 2016 and now state "I may revoke this authorization at any time. Revocations to this authorization may be requested verbally or in writing."
The Admissions Director will review 20 charts per month to ensure we are using the correct Release forms to meet this regulation. |
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.
|
Observations
Based on a review of twenty-three client records on June 20-22, 2016, the facility failed to offer a copy of a consent to release information to the client in three of twenty-three client records reviewed.
Client #4 was admitted on January 4, 2016. A consent to the funding source was not dated and did not indicate whether a copy was offered to the client.
Client #13 was admitted on February 9, 2016. Consents dated 2/9/2016 to the funding source, client's PCP and a pharmacy did not indicate that a copy was offered to the client.
Client #23 was admitted on February 10, 2016. Consents dated 2/10/2016 to the funding source, a pharmacy, and legal agencies did not indicate that a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of August 1, 2016 all staff will be re-trained to document that a copy of the consent was offered to the client. The Admissions Director will review 20 charts per month to ensure this regulation is met. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
|
Observations
Based on the physical plant inspection of the inpatient rehab nursing station on June 21, 2016, the facility did not secure controlled substances per state and federal requirements.
Several sets of facility keys along with a charging device were observed in the double-locked narcotic drawer in the nursing cart along with the controlled substances.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The nursing staff will be educated/ reeducated on this regulation in the nurses meeting on 7-27-16 by the Director of Nursing. The Director of nursing will also send the information out in an email to nursing staff by 7-27-16.
There is currently nothing other than medications in the Drug storage areas. The Director of nursing or designee will do a check of all medication areas once a month for 6 months to ensure compliance.
|
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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:
|
Observations
Based on a review of eight client records on June 20-21, 2016, four client records did not contain an individual treatment and rehabilitation plan developed with the client for the partial hospitalization program.
Client #11 was admitted April 4, 2016 and was discharged April 10, 2016 without a plan developed during the intake process.
Client #13 was admitted February 9, 2016 and discharged March 10, 2016 without a plan being developed during the intake process.
Client #14 was admitted on January 18, 2016 and was discharged on February 13, 2016 without a plan being developed during the intake process.
Client #15 was admitted December 4, 2015 and was discharged January 1, 2016 without a plan being developed during the intake process.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The new partial counselor will be trained on the required timeframe to complete an individualized treatment plan. The Clinical Supervisor will review the clinical binder 2x/month to ensure this standard is met. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of eight client records on June 20-21, 2016, four clients did not receive their individual treatment according to their treatment plans for the partial hospitalization program.
Client #8 was admitted on June 8, 2016 and is still an active client. The client was to receive individual counseling sessions once per week and was not seen for individual treatment prior to the date of inspection.
Client #9 was admitted on June 1, 2016 and is still an active client. The client was to receive individual counseling sessions once per week and was only seen on 6/8/16 prior to the date of inspection.
Client #10 was admitted on June 3, 2016 and is still an active client. The client was to receive individual counseling sessions once per week and was only seen on 6/16/16 prior to the date of inspection.
Client #14 was admitted on January 18, 2016 and was discharged on February 13, 2016. The client was to receive individual counseling sessions once per week and was not seen for individual treatment prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The new partial counselor will be trained on the required documentation and standard for individual counseling session.
The Clinical Supervisor will review the clinical binder 2x/month to ensure compliance with this regulation. |
709.83(a) 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:
|
Observations
Based on a review of eight client records on June 21-22, 2016, the facility failed to ensure that a complete record was documented in three of eight records reviewed for the partial hospitalization program.
Client # 13 was admitted on February 9, 2016 and discharged on March 10, 2016. A record of service was not documented in the client's record, although there were progress notes for therapy sessions received by the client. Also, a preliminary treatment plan was missing.
Client #15 was admitted on December 4, 2015 and discharged on January 1, 2016. A record of service was not documented in the client's record, although there were progress notes for therapy session received by the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Staff will be re-trained on the required Record of Service documentation. The Clinical Supervisors will review the clinical binders 2x/month to ensure compliance.
Upon discharge, the Medical Records staff will also review the chart to ensure the Record of Service was completed. |
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.
|
Observations
Seven patient records were reviewed on June 20-22, 2016 for documentation of initial drug- screening urinalysis at the time of admission or re-admission. The facility failed to document when the urine test was collected in patient record # 4 and # 7.
Client #4 was admitted on January 4, 2016 and dosed on January 6, 2015. A urine test was completed but the facility failed to document the date the urine test was administered.
Client #7 was admitted on May 9, 2016 and dosed on May 10, 2016. A urine test was completed but the facility failed to document the date the urine test was administered.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All new clients will receive a drug-screening urinalysis. Prior to all clients being dosed the results of the drug screen urinalysis need to be available. A copy of the results will be filed by the dosing nurse in the chart. The Director of Nursing will educate the dosing nurses on this individually by 7-29-16. The Director of Nursing will also add it to the methadone daily checklist that gets completed by the doing nurse and spot check 10 charts per month to ensure compliance.
Also, the UDS results were obtained for Client #4 on January 5, 2016 and on May 10, 2016 for Client #7. Both UDS reports are available in the patient records at this time. |
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.
|
Observations
Based on a review of eight client records on June 20-21, 2016, two clients did not receive their individual treatment according to their treatment plans for the inpatient program.
Client #16 was admitted on June 1, 2016 and is still an active client. The client was to receive individual counseling sessions once per week and was only seen on 6/7/16 prior to the date of inspection.
Client #18 was admitted on May 31, 2016 and is still an active client. The client was to receive individual counseling sessions once per week and was not seen for individual treatment prior to the date of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The counseling staff will be re-trained on the required documentation of one individual session per week.
The Clinical Supervisor will review the clinical binders 2x/month to ensure compliance. |