INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection VRL66701 Bridgeway House was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
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Plan of Correction
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§ 717.20(a)(1) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(1) All records obtained under § 717.22.
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Observations
Based on a review of resident records, the recovery house failed to maintain an individual record.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
As of August 26, 2024, Bridgeway House has been fully compliant with regulation 717.22. The Director provided training to the house manager on how to add columns to the census to accurately reflect the reasons for departure. The census will continue to encompass all components of 717.22, including the following: - Residency criteria - Requirements for completion of residency by meeting a resident's treatment, personal, or financial goals, as well as social-emotional or other needs - Criteria for ending residency before completion, including a specified timeline - Completion of all necessary documentation, signed by the resident within 24 hours of arrival - Disclosure to the resident of criteria for beginning and ending residency - Resident orientation to the drug and alcohol recovery house, covering house rules, recording of residents' expected return time, fee schedule, supports provided, financial policies, and procedures - Referrals to other essential services as needed - The posted emergency procedures and contact information for the house manager and the Department, as well as the medication control and self-administration policies, will be located in a prominent position. Basic personal data to be included are: - Name - Birth date - Demographic information - Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker, and other medical conditions chosen by the resident to be included in the house record - Drug and alcohol history - Medical contact information - Emergency contact - Consent to residency - Disclosure to the resident of the recovery house's policies and procedures for situations when recovery house staff may notify the resident's emergency contact. The director will continue to monitor the house manager's progress and documentation every 30 days. If issues persist, the house manager will receive a written warning. After three write-ups, the house manager will face termination.
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§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on a review of resident records, the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The director and house manager will conduct a thorough review of all discharges, meticulously comparing them to the end of residency forms. It is imperative to ensure that the discharges documented in the census align precisely with the reasons for ending residency as stated on the end of residency forms. This comprehensive review process is scheduled to be finalized by September 12, 2024. Looking ahead, the director will implement a proactive approach by instituting weekly checks of all documentation to guarantee Bridgeway House's compliance with DDAP regulations. In the event of any discrepancies or errors, the director will organize specialized training sessions for the house managers, equipping them with the necessary knowledge and skills to accurately conclude residency for residents. Furthermore, the end of residency forms will be diligently completed at the time of termination, ensuring that a clear time frame and reason are explicitly provided on the forms. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on a review of the fire extinguishers located throughout that property, the recovery house failed to have a fire extinguishers inspected and approved annually by the local fire department or fire extinguisher company.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
In strict adherence to regulation 717.30, it is confirmed that as of August 29, 2024, all fire extinguishers have undergone thorough inspection and have been approved with the ABC certification by the fire department. This certification serves as a testament to the safety and preparedness measures in place at the property. Looking ahead, the director is committed to proactively ensuring the safety and compliance of the property. To this end, the director will take proactive steps to arrange for the fire department to conduct an inspection prior to DDAP's scheduled on-site visit. This strategic planning will involve coordinating with the fire department to schedule their visit 60 days before DDAP's inspection. This proactive approach allows ample time to address any potential issues or replace extinguishers, if necessary, thereby ensuring that the property is fully prepared and compliant with all safety regulations well in advance of the official inspection. |