INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 13, 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an administrative review of staffing schedules and CPR certification cards, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
The facility hours of operation are 8 AM to 4:30 PM, Monday through Sunday (seven days a week). The only employee scheduled to work at the facility every Sunday was not currently CPR certified at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality Management Director will be responsible for ensuring completion of trainings on time. Documentation of completed trainings will be maintained in the employee's file.
All staff are CPR certified as of July 12, 2023.
The quality director will create a spreadsheet for PHP staff and CPR certification. The quality director will inform the appropriate manager and CEO within 60 days of ones CPR training being expired so appropriate time is available for recertification. |
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 one of one applicable personnel record reviewed.
Employee # 4 was hired as a counselor on January 20, 2021. The personnel record documented zero hours 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.
The Quality Manager 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 manager will develop a spreadsheet to track training hours for PHP staff. Quarterly updates of where each PHP employee stands with required training hours will be given to the counselor, clinical supervisor and clinical director. |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection conducted, the facility failed to keep cold food at or below 40 hot food at or above 140 and frozen food at or below 0 The standing freezer, located in the kitchen, registered a temperature above 0 at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The date, temperature and initials of the staff checking the freezer temperature will be documented on the freezer log daily to ensure freezer temperature is at or below 0. The log will be kept on the front of the freezer.
The freezer with serviced by maintenance on 6/29 and on 6/30 the freezer was below 0
The quality management director will check this log weekly for the next 3 months to ensure daily logs are being kept and temperatures fall within the appropriate range.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's June 2022 through June 2023 fire drill log, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
There were no fire drills conducted during the months of June 2022 through November 2022, January 2023, and March 2023 through May 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 Facilities Manager to ensure that unannounced fire drills are conducted monthly and logged.
In compliance before July 31, 2023
The quality director will review documentation for unannounced fire drills monthly for the next 4 months. If 5 days of the month are left and no fire drill occurred, the quality director will meet with the facility manager to ensure an unannounced fire drill is scheduled prior to the end of the month. Documentation of that drill will be reviewed after the drill occurs.
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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, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in six of ten client records.
Client #1 was admitted on May 8, 2023 and was active at the time of inspection. There was documentation of disclosures to a urinalysis laboratory on May 12, 2023 and May 18, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #3 was admitted on May 26, 2023 and was active at the time of inspection. There was documentation of disclosure to a urinalysis laboratory on May 30, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #4 was admitted on October 14, 2022 and was discharged on November 14, 2022. There was documentation of disclosure to a urinalysis laboratory on October 15, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #6 was admitted on March 16, 2023 and was discharged on April 30, 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.
Client #7 was admitted on August 24, 2022 and was discharged on September 9, 2022. 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.
Client #10 was admitted on March 16, 2023 and was discharged on April 25, 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.
This is a repeat citation from the June 3, 2021 and May 25, 2022 annual licensing renewal inspection.
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.
Clients #1, 3, 4, 6, 7 and 10 are no longer in treatment and consents are not able to be re-done.
The quality director will review 10 client files for the next 3 months to ensure a written and voluntary consent is in the file. |
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 disclosed on consent to release information forms in three of ten client records reviewed.
Client #8 was admitted on September 6, 2022 and was discharged on September 27, 2022. The release of information form to a parole officer was signed and dated by the client on September 13, 2022, but the release form did not include the specific information to be disclosed.
Client #9 was admitted on June 14, 2022 and was discharged on July 15, 2022. The release of information form to a family member was signed and dated by the client on June 14, 2022, but the release form did not include the specific information to be disclosed.
Client #10 was admitted on March 16, 2023 and was discharged on April 25, 2023. The release of information form to a family member was signed and dated by the client on March 17, 2023, but the release form did not include the specific information to be disclosed.
This is a repeat citation from the May 25, 2022 annual licensing renewal inspection.
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.
The quality director will review 10 client files for the next 3 months to ensure the specific information to be disclosed is on the consent to release 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 five of ten client records reviewed.
Client #1 was admitted on May 8, 2023 and was active at the time of inspection. There were release of information forms to a pharmacy, probation and parole, and a healthcare service that were signed and dated by the client on May 9, 2023; however, there was no documentation that a copy of any of the consent forms were offered to the client.
Client #3 was admitted on May 26, 2023 and was active at the time of inspection. There were release of information forms to a person, another treatment provider, a pharmacy, a funding source, and a healthcare service that were signed and dated by the client on May 31, 2023; however, there was no documentation that a copy of any of the consent forms were offered to the client.
Client #6 was admitted on March 16, 2023 and was discharged on April 30, 2023. There were release of information forms to an emergency contact and a healthcare service that were signed and dated by the client on March 18, 2023; however, there was no documentation that a copy of any of the consent forms were offered to the client.
Client #8 was admitted on September 6, 2022 and was discharged on September 27, 2022. There was a release of information forms to a parole officer that was signed and dated by the client on September 13, 2022; however, there was no documentation that a copy of the consent form was offered to the client.
Client #10 was admitted on March 16, 2023 and was discharged on April 25, 2023. There were release of information forms to an emergency contact, a family member, a pharmacy, a physician, and a government agency that were signed and dated by the client on March 17, 2023; however, there was no documentation that a copy of any of the consent forms were offered to the client.
This is a repeat citation from the May 25, 2022 annual licensing renewal inspection.
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 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.
Clients #1, 3, 6, 8 and 10 are no longer in treatment and consents are not able to be re-done.
The quality director will review 10 client files for the next 3 months to ensure there is documentation that a copy of 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.
On June 13, 2023, the facility was unable to efficiently produce a discharged client list at the facility. Prior to the inspection, the DDAP representatives requested a discharged client list to be ready upon their arrival on the day of the inspection. The discharged client list was not available to the DDAP representatives until over an hour and a half after arriving to the facility. Facility staff stated that the facility does not have the ability to produce a discharged client list on-site and that the list must be created by a central business office and emailed to the facility.
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 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) (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 June 2022 through June 2023 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on July 21, 2022 and January 31, 2023.
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 July 21, 2022 and January 31, 2023 by August 12, 2023 situations that required the presence of the police and/or ambulance.
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 the police and/or ambulance being at the facility.
The CEO will complete random audits of unusual incident reports after the presence of police or ambulance over the next 4 months to ensure timely completion and submission to the department. |
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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that is to be developed with the client in four of ten client records reviewed.
Client #1 was admitted May 8, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on May 10, 2023 and the client signed and dated the plan on May 22, 2023. There was no documentation that the plan was developed with the client.
Client #2 was admitted May 26, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was signed and dated by facility staff on May 26, 2023 and the client signed and dated the plan on May 31, 2023. There was no documentation that the plan was developed with the client.
Client #6 was admitted on March 16, 2023 and was discharged on April 30, 2023. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of inspection.
Client # 10 was admitted on March 16, 2023 and was discharged on April 25, 2023. There was no documentation, in the record, of an individual treatment and rehabilitation plan at the time of 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 a comprehensive and individualized treatment plan with each client. Education will take place by 8/15/23.
The quality director/clinical supervisor will monitor 10 charts for the next 3 months to ensure each client has a treatment plan which shoes it was written with the client.
Clients #1,2 6 and 10 are no longer in treatment and their treatment plans cannot be completed with them. |
709.82(a)(2) 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:
(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 and rehabilitation plan in three of nine applicable client records reviewed.
Client #1 was admitted May 8, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 10, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted May 26, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 26, 2023; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #3 was admitted May 26, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 31, 2023; however, the plan 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 clinical director will re-educate clinical staff on the importance of documenting the type and frequency of treatment and rehabilitation services on the client's treatment plan.
Education will take place by 8/15/23.
Client's #1,2 and 3 are no longer in treatment and the treatment plan can no longer be revised with them.
The clinical supervisor/quality director will monitor 10 charts for the next 3 months to ensure the type and frequency of treatment and rehabilitation services are on the treatment plan.
These audits will be turned into the Quality Manager. Clinical supervisors will ensure compliance. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that clients received individual counseling services on a regular and scheduled basis, specifically providing individual counseling at least twice weekly, in eight of ten client records reviewed.
Client #1 was admitted on May 8, 2023 and was active at the time of inspection. The progress notes indicated that the client received one individual session on May 14, 2023, for the week of May 14, 2023 through May 20, 2023, and only two individual sessions on May 31, 2023 and June 6, 2023, for the weeks of May 28, 2023 through June 10, 2023.
Client #2 was admitted on May 26, 2023 and was active at the time of inspection. The progress notes indicated that the client received one individual session on June 8, 2023, for the week of June 4, 2023 through June 10, 2023.
Client #3 was admitted on May 26, 2023 and was active at the time of inspection. The progress notes indicated that the client received one individual session on June 8, 2023, for the week of June 4, 2023 through June 10, 2023.
Client #4 was admitted on October 14, 2022 and was discharged on November 14, 2022. The progress notes indicated that the client received one individual session on October 19, 2022, for the week of October 16, 2022 through October 2022, and only two individual sessions on November 2, 2022 and November 6, 2022, for the weeks of October 30, 2022 through November 12, 2022.
Client #5 was admitted on August 9, 2022 and was discharged on September 1, 2022. The progress notes indicated that the client received only two individual sessions on August 17, 2022 and August 23, 2022, for the weeks of August 14, 2022 through August 27, 2022.
Client #6 was admitted on March 16, 2023 and was discharged on April 30, 2023. There was no documentation, in the record, of individual counseling sessions occurring throughout the treatment episode.
Client #7 was admitted on August 24, 2022 and was discharged on April 30, 2023. The progress notes indicated that the client received only one individual session per week throughout the treatment episode.
Client #10 was admitted on March 16, 2023 and was discharged on April 25, 2023. There was no documentation, in the record, of individual counseling sessions occurring throughout the treatment episode.
This is a repeat citation from the June 3, 2021 and May 25, 2022 annual licensing renewal 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 providing a minimum of two individual sessions weekly for each individual in PHP.
Education will take place by 8/15/23.
Client's #1,2,3,4,5,6,7 and 10 are no longer in treatment and two individual counseling sessions per week can no longer occur.
The clinical supervisor/quality director will monitor 10 charts for the next 3 months to ensure a minimum of two individual sessions are occurring weekly. The audits are facilitated twice a week.
Clinical supervisors will ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the June 3, 2021 and May 25, 2022 annual licensing inspections. Failing to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record was again found to be a deficiency in the June 13, 2023 licensing inspection.
A plan of correction for failing to ensure that clients receive individual sessions at least twice weekly was submitted and approved by the Department for the June 3, 2021 and May 25, 2022 annual licensing inspections. Failing to ensure that clients received individual sessions at least twice weekly was again found to be a deficiency in the June 13, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO and Compliance Manger will develop auditing tool to ensure every Manager and Supervisor are incompliance with the approved Plan of Correction. The compliance manager with meet regularly with the leadership team to review the POC for consistent compliance. |