INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dreamlife Recovery 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of October 2023 through August 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was only one overnight fire drill documented on August 29, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Facilities will conduct a fire drill overnight at least once every 6 months. This will be audited each quarter to ensure that it is following the guidelines.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in two of five applicable records.
Client #1 was admitted to inpatient on July 28, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 5. 2024. A treatment and rehabilitation plan update was due no later than September 5, 2024, but was not completed at the time of the inspection.
Client #3 was admitted to inpatient on July 17, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on July 23. 2024. A treatment and rehabilitation plan update was due no later than August 23, 2024, but was not completed until August 27, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan reviews will be consistently completed by the 30th day from the treatment plan creation date. The lead therapist, the Clinical Program Manager and the Chief of Clinical Care Services will review these monthly for completion and compliance. |