INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 9-10, 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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705.2 (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 a physical plant inspection conducted on September 9, 2025, along with the review of administrative documentation, the facility failed to keep the grounds safe and in good repair.The roofing assessment conducted by JEMCO Construction, LLC Roofing Corporation, indicates the roof is in poor condition. A new roof installation was recommended on May 29, 2025.The 4th floor stairwell landing by the elevator was observed to be missing the cove base and floor tileResident bedroom # 427 has a torn material on the headboard.Loose baseboards were observed in resident bedrooms 422, 411, 326, 318, and 312.Resident bedroom # 409 has an electrical outlet box appearing to be missing a cover as it was wrapped with black tape holding it together.Resident bedroom # 310 was observed to have a hole in the wall.Resident bedroom # 112 was observed to have a broken plastic wire cover with sharp edges on the wall below tv.
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Plan of Correction
1. Facilities Assistant
Who: Facilities Assistant
What: 4th floor landing tile--already fixed, cove and base--already fixed, ripped headboard is already fixed. Loose baseboards are already replaced, electrical outlet--already fixed, hole is already fixed, sharp edges on the plastic cover wire is already fixed.
2. Facilities Director
Who: Facilities Director
What: Will review each item to confirm completion and report back to the Chief of Clinical Care.
By When: 11/10/25
3. Dreamlife BHT Staff
Who: Dreamlife BHT Staff
What: Will conduct a walkthrough of the facility and all client rooms each month to ensure nothing is broken or in need of repair.
By When: Monthly, ongoing.
4. Chief of Clinical Care Services
Who: Chief of Clinical Care Services
What: Will email all staff by 11/10/2025 reminding them to use the maintenance email thread to report anything that needs fixing or repair as soon as it is noticed, and that it will be fixed or repaired within the week.
By When: Email sent by 11/10/2025; repairs to be completed within one week of being reported.
5. ROOF
Who: Centrimark
What: will repair the roof
By when: We are waiting to get a date from the company on when they will be here but they state that it will be before year end. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection conducted on September 9, 2025, the facility failed to maintain furnishings in a state of good repair.A blue chair in the male lounge on the 3rd floor was observed to have worn vinyl-like material, has scratches on the wooden arms and is missing an upholstery button.
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Plan of Correction
1. Facilities Assistant
Who: Facilities Assistant
What: Remove the Chair
By When: By 11/1/2025.
2. Facilities Director
Who: Facilities Director
What: Will ensure it is removed
By When: 11/10/25
3. Dreamlife BHT Staff
Who: Dreamlife BHT Staff
What: Will conduct a walkthrough of the facility and all client rooms each month to ensure everything is in good repair.
By When: Monthly, ongoing.
4. Chief of Clinical Care Services
Who: Chief of Clinical Care Services
What: Will email all staff by 11/10/2025 reminding them to use the maintenance email thread to report anything that is not in good repair and that it will be fixed or repaired within the week.
By When: Email sent by 11/10/2025; repairs to be completed within one week of being reported. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on September 9, 2025, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.A black mold-like substance was observed on the front shower caulking strip at the floor, on the ceilings and walls of the bathrooms in bedrooms 423, 429, 427, 422, 411, 409, 322, 316, 313, 311, 309, 107, 110.The toilet paper holder was observed to be broken in the bathrooms of bedrooms 426 and 427.Peeling wallpaper, stucco, and paint was observed in the bathrooms of bedrooms 411, 330, 328, 326, 324, 323, 322, 320, 312, 309, 105, 111, 110.White vanity drawer pull was observed to be partially attached and hanging in the bathroom of bedroom # 326.The bathroom in bedroom # 310 was observed to have a rusty shower rod.
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Plan of Correction
1. Facilities Assistant and Housekeeping
Who: Facilities Assistant and Housekeeping
What: Will ensure that everything is clean and sanitary.
Toilet paper holding is fixed, peeling wallpaper, stucco and paint will be completed by 11/1/25, white vanity drawer was fixed, bathroom shower rod was already replaced.
By When: By 11/1/2025.
2. Facilities Director
Who: Facilities Director
What: Will review the facility to ensure that it is clean and sanitary at all times.
By When: 11/10/25
3. Dreamlife BHT Staff
Who: Dreamlife BHT Staff
What: Will conduct a walkthrough of the facility and all client rooms each month to ensure that everything is clean and sanitary.
By When: Monthly, ongoing.
4. Chief of Clinical Care Services
Who: Chief of Clinical Care Services
What: Will email all staff by 11/10/2025 reminding them to use the housekeeping email thread to report anything that is not clean and sanitary and that it will be cleaned and sanitized within the week.
By When: Email sent by 11/10/2025; repairs to be completed within one week of being reported.
5. Servpro was called to assess for black mold and came onsite the next day to review the concerns. They stated that they could test the rooms that are listed here and one additional room they recommended. They came on 9/17/25 to test the rooms. On 9/22/25 we received the results and only one room tested positive for mold. The room was shut down and will be remediated per the suggestions of Servpro. The results of the testing were sent to DDAP on 10/2/25. The room will not be reopened until the mold remediation is completed. |
709.63(a)(7) LICENSURE Discharge summary
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(7) Discharge summary.
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Observations
Based on a review of client charts and the Residential Scope of Services Policy, the facility failed to document a discharge summary per their policy in one of four charts reviewed.The Residential Scope of Services Policy indicates a discharge summary is to be completed within 7 days after discharge.Client # 1 was admitted on February 18, 2025, and discharged on February 21, 2025. The discharge summary is dated March 5, 2025.
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Plan of Correction
The Lead Therapist and the Clinical Program Manager will review charts to ensure that the discharge summary is being completed in the 7 day time frame consistently. The Lead Therapist will conduct monthly chart audits for QI and will report on this as well to ensure completion. In this situation, the client went to the hospital and was then discharged once it was determined that they were not returning back. The therapist used the date the client went to the hospital instead of the date it was decided that the client would not return. Therapists will be educated by 11/10/25 to use the date the decision was made not the date they left in situations like this in the future. |