INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 23-24, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Bradford Recovery Center 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on staff and patient interviews, the facility failed to ensure the safety and well-being of patients, staff and visitors. The Patient Search policy is not being adhered to. Per an interview with the program director, there have been six incidents between December 2021 and February 2022 where illegal substances or drug paraphernalia were discovered in the facility.The Patient Search policy states that all searches are to be completed by two staff members and the patient will be observed during the entire process. Four out of seven patients interviewed stated there was only one staff member present during the search process. One out of seven patients interviewed stated they changed clothes without being observed during the search process.
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Plan of Correction
The Facility Director will provide all staff education and training on the facilities patient search policy and requirements as outlined in 705.2(2). The education/training will be provided by April 8th 2022. All new hires will be provided and trained on the facilities patient search policy at orientation. All staff members will be provided refresher training on the facilities patient search policy every 6 months. Training completion documentation will be placed in each staff members personnel file. The facility Human Resource Manager will monitor staff files for noncompliance. The HR Manager will report the monitoring outcomes at the weekly Leadership meeting to ensure continued compliance. |