INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted August 3, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Bradford Recovery Center was not found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
|
Observations
Based on a complaint investigation conducted on August 3, 2022, the facility failed to ensure that the facility was free of insect infestation.
An excessive amount, of flies were observed throughout the facility. Clients reported having to cover their food with napkins to keep the flies off of their food. Flies were observed throughout the dining room, the kitchen and on the food that was plated for clients to eat.
Additionally, fly tape was hanging in the kitchen food preparation area with dead flies attached to it which was in close proximity to food. This was discussed with facility staff during the investigation.
This was discussed with facility staff during the investigation.
|
Plan of Correction
The Facility Manager shall ensure the facility is free from rodent and insect infestation, as outlined in 705.9.
08/17/2022 Onsite Inspection by a Pest Control ("company") was completed for flying insects. Recommendations received from "company" have been implemented.
As recommended, the facility placed additional flying insects' alpine, food safe, baits and other wall sconce blue light devices to control deterrents throughout the affected areas.
The "company" will increase onsite inspections and treatments to monthly.
Weekly Leadership rounds will be conducted, and any areas of concerns will be immediately reported to the Director, Program Management, and if needed the "company" will be contacted for additional treatments.
|
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
|
Observations
Based on a review of staff terminations and disciplinary write-ups since January 2022, the facility was found to have gross incompetence, negligence or misconduct in the operation of the facility and to have mistreated or abused individuals cared for or treated by the facility.
Employee #1 was reprimanded for leaving the nurses station unmanned, taking detox clients out of the view of the camera twice and leaving the nurses station for 4 hours. This was reported on a reprimand dated 7/5/22.
Employee # 8 was terminated for falsifying documents when she failed to complete bed checks and for not leaving her office to do room checks for 5 hours. This was reported on a reprimand dated 2/16/22.
There were ten employees with reprimands and/or terminations for
boundary violations since February 2022.
Employee #1 was terminated on 7/5/22 for inappropriate social relationships with clients.
Employee #2 was merely reprimanded on 7/5/22 for inappropriate social relationships with clients.
Employee #3 was terminated on 5/13/22 for an inappropriate relationship with a client. Employee #4 was terminated on 6/8/22 for an inappropriate relationship with a client. Employee # 5 was reprimanded on 7/22/22 for inappropriate behavior toward a client. Employee #6 was reprimanded on 5/18/22 for not reporting an inappropriate relationship between employee #3 and a client in addition to engaging in phone texts with a client.
Employee # 7 was issued a verbal warning on 7/22/22 on boundaries, and the facility is currently conducting an investigation into inappropriate contact with a client at the time of this complaint investigation.
Employee #8 was terminated on 2/16/22 for inappropriate behaviors with clients.
Employee #9 was reprimanded on 7/5/22 for inappropriate social relationships with clients.
Employee #10 was reprimanded 5/20/22 for not reporting an inappropriate relationship between employee #3 and a client in addition to engaging in phone texts with a client.
|
Plan of Correction
In review of the findings there was actually nine employees not ten (one tag included duplicate employee) our review found five violations in relation to HR Policy 215. The facility took disciplinary action within 48 hours which included the below
- 3 terminations
- 2 final written disciplinary actions
The remaining 4 were related to not following policies e.g., reporting violations of facilities and companies' policies and procedures, and or social media policies.
* Specific details of each review are available
The facility shall ensure all staff are oriented to the state and facilities rules and requirements upon hire.
All new staff is provided an employee handbook (which includes Zero Tolerance and Boundaries Policies, as well as the employee Code of Conduct) at New Hire Orientation.
Program will ensure all New Hire Orientation includes these topics and policies as evidenced by successful completion of a post training exam, as well as a completed training summary which will be available in the employee's file.
The HR Manager is responsible for monitoring and tracking all employee trainings in centralized file to ensure compliance.
Additional Zero Tolerance training 07-08-2022
Boundaries Training 05-26-2022 which included posttest.
Transference and Countertransference training was completed 08-24-2022,
In addition, all staff reviewed and signed acknowledgment of Client Rights on 09-06-22.
*See previous correction to employee counts
|
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
|
Observations
Based on a complaint investigation conducted on August 3, 2022, the facility failed to provide the investigators with the facility's Zero Tolerance policy and the Staff Code of Ethics.
During the investigation, the facility staff referenced the facility's Zero Tolerance policy. The facility was unable to provide this policy during the investigation. The Staff Code of Ethics was also requested but not provided.
|
Plan of Correction
The facility will complete an 100% audit to ensure all applicable policies and procedures are current and accessible to staff and outside agencies in hardcopy and electronic.
The Director, Program Management is responsible for completing by 09/15/2022
|
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
|
Observations
Based on a review of the facility's Patient & Resident Rights, Boundaries policy, staff terminations and disciplinary reprimands,The facility failed to ensure adherence to their Patient & Resident Rights. These rights include: implementing policies promoting confidentiality of client information, privacy, freedom from abuse, financial or other exploitation, retaliation, humiliation and neglect; to be free from abuse (mental, sexual and physical abuse), financial or other exploitation and coercive acts by staff and other patients; access to treatment, adequate and humane services.
There were ten employees with reprimands and/or terminations for boundary violations since February 2022.
Employee #1 was terminated on 7/5/22 for inappropriate social relationships with
Clients.
Employee #2 was reprimanded on 7/5/22 for inappropriate social relationships with clients.
Employee #3 was terminated on 5/13/22 for an inappropriate relationship with a client. Employee #4 was terminated on 6/8/22 for an inappropriate relationship with a client. Employee #5 was reprimanded on 7/22/22 for inappropriate behavior toward a client. Employee #6 was reprimanded on 5/18/22 for not reporting an inappropriate relationship between employee #3 and a client in addition to engaging in phone texts with a client.
Employee #7 was issued a verbal warning on 7/22/22 on boundaries, and the facility is currently conducting an investigation into inappropriate contact with a client at the time of this complaint investigation.
Employee # 8 was terminated on 2/16/22 for inappropriate behaviors with clients.
Employee #9 was reprimanded on 7/5/22 for inappropriate social relationships with clients.
Employee #10 was reprimanded on 5/20/22 for not reporting an inappropriate relationship between employee #3 and a client in addition to engaging in phone texts with a client.
|
Plan of Correction
The facility shall ensure the written client rights are followed by all staff.
The Patient and Residents Rights policy was disseminated to all staff as evidenced by a signed, dated copy to ensure staff adhere to policy.
The facility shall ensure clients are informed of client rights upon admission and written acknowledgment of notification of client rights will be documented in the client medical record in the form of an admission orientation checklist, patient handbook with signed acknowledgment. Awareness of potential Transference while in treatment, how to process, report will be included in client orientation/handbook which addresses Friendship versus therapeutic relationship.
Patient and Resident Rights, Boundaries topics will be added to each department's meeting's agendas.
The Director, Program Management or clinical designee will ensure ongoing training, transparency and monitoring occurred. Any perceived transference or countertransference will immediately be addresses in a patient staffing meeting.
This plan will be complete by 9-15-22.
*See previous correction to employee counts
|
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
Based on a reivew of staff terminations and reprimands since February 2022, the facility failed to file a written Unusual Incident Report with the Department as required. Facility documentation showed multiple episodes of patient abuse occurred which was not reported to the Department.
There were ten employees with reprimands and/or terminations for boundary violations since February 2022.
Employee #1 was terminated on 7/5/22 for inappropriate social relationships with clients. Employee #2 was merely reprimanded on 7/5/22 for inappropriate social relationships with clients.
Employee #3 was terminated on 5/13/22 for an inappropriate relationship with a client. Employee #4 was terminated on 6/8/22 for an inappropriate relationship with a client. Employee #5 was reprimanded on 7/22/22 for inappropriate behavior toward a client. Employee #6 was reprimanded on 5/18/22 for not reporting an inappropriate relationship between employee #3 and a client in addition to engaging in phone texts with a client. Employee #7 was issued a verbal warning on 7/22/22 on boundaries, and the facility is currently conducting an investigation into inappropriate contact with a client at the time of this complaint investigation.
Employee #8 was terminated on 2/16/22 for inappropriate behaviors with clients. Employee #9 was reprimanded on 7/5/22 for inappropriate social relationships with clients.
Employee #10 was reprimanded on 5/20/22 for not reporting an inappropriate relationship between employee #3 and a client in addition to engaging in phone texts with a client.
|
Plan of Correction
The facility will ensure written Unusual Incident reports are filed within 48 hours following an unusual incident as outlined in 715.28(c) (1-5).
The facility will re-educate all staff on the requirements for timely review and reporting unusual incidents immediately.
Any unusual Incident Reports will be submitted to the Director, Program Management for review, investigation, and submission to the state using the Unusual Incident reporting form.
The Director of Nursing will be delegated as designee to review and report in the absence of the Director, Program Management.
The Director, Program Management is responsible for following companies processes for reporting Unusual Incidents to direct supervisor and compliance department.
Monthly or more frequently if needed Unusual Incidents will be reviewed with Senior Leadership to determine if changes, action and/or revisions are needed.
*See previous correction to employee counts
|