INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 14, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Dreamlife Recovery LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that there were no heaters that were not permanently mounter or installed. A space heater was observed in a first floor staff office that is located behind the area where visitors sign into the facility.
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Plan of Correction
The Facilities Director will make sure that no heaters that are not permanently mounted or installed will be used facility wide. The Facilities Director will conduct a walk through to ensure compliance at least monthly during the monthly safety review. The space heater was removed from the premises. |
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 an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 1 was admitted on September 19, 2024, and discharged on October 30, 2024. There was no documentation of an informed and voluntary consent to release information to an aftercare provider prior to aftercare being set up for this client.
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Plan of Correction
The BHT Manager will ensure that consents are getting signed on admission when possible for facilities that we coordinate with. The case manager will make sure that a consent is in place prior to collaborating with another treatment center including our own sister agencies. Staff will be educated to ensure understanding and the Lead Therapists will ensure that they are reviewing charts monthly to audit that it is occurring. |
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 client charts and internal incident reports during a complaint investigation that was conducted on January 14, 2025, the facility failed to inform the Department of an unusual incident involving the presence of police, fire or ambulance personnel, within the required three days.
On October 30, 2024, there was an incident involving police being called onto the premises. The facility did not submit a written report to the Department on this incident.
On November 4, 2024, and November 19, 2024, there were incidents in which ambulance personnel were called onsite. The facility did not submit a written report to the Department on these incidents until January 9, 2025.
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Plan of Correction
The Director of Nursing will start logging incidents that occur that involve police or ambulance and will ensure that for each situation an incident report is completed by nursing or appropriate staff members. The Director of Nursing will also then enter these into the ERS system within 3 days of the incident. The Director of Nursing will audit the incident reports comparative to emails to ensure all were completed accurately and timely each month. |