INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 7, 2025, 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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705.6 (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 October 7, 2025, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. Paint was observed to be peeling off the wall behind the shower in the bathroom of room 101.
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Plan of Correction
Maintenance Director has repaired the wall in room 101. During monthly leadership rounds, staff will continue to look for impairments throughout the building. If located, these impairments will be reported to the Maintenance Director for immediate repair.
The CEO will monitor monthly leadership rounds forms for the next 90 days to ensure consistency in needed repairs.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted on October 7, 2025, the facility failed to store all food items off the floor. In the kitchen, a bag of potatoes, a box of canned spaghetti sauce, and a box of vegetable frying oil were observed to be stored on the floor.
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Plan of Correction
All dietary staff have completed a supervision to comply with policy 705.7. The group supervision was completed on 10/21/25.
The CEO will meet bi-weekly with the dietary manager to ensure proper storage for food items is consistently handled properly. The CEO will inspect, which will also be included as part of the monthly leadership rounds conducted by staff, dietary space over the next 90 days to ensure foods and maintained and stored properly.
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709.84(d) LICENSURE Project management services
709.84. Project management services.
(d) The project shall develop a written client aftercare policy.
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Observations
Based on a review of the Aftercare Plan and Treatment Engagement Plan policy, the Discharge policy, and the Documentation Requirements policy, the project failed to develop a current written client aftercare policy. Per the Facility Director, the policies on aftercare planning were completed using their old electronic medical record system. They include documentation that is no longer available on their current electronic medical record system.
The Aftercare Plan and Treatment Engagement Plan policy indicates an Aftercare Plan is completed if a client refuses a referral to another level of care or is discharged home from any level of care without a referral being made to another provider. At any other time, a Treatment Engagement Plan is completed.
The Discharge policy indicates information will be documented on the clients ' continuing care/transition plan.
The Documentation Requirements policy indicates the Continuing Care/Transition Plan is offered to the patient at the time of discharge with clear instructions for follow-up.
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Plan of Correction
Policy change has been created and implemented. The new policy states, "In the case of premature discharges (Against Medical Advice, Administrative Discharge, Medical Discharge), this must be documented in a progress note and placed in the chart. All attempts will be made to provide a copy of the Aftercare Plan(s) to the client. Record reviews will be conducted weekly by our Quality Control staff and Clinical Director. An emphasis will be placed on reviews of premature discharges and client's receiving a copy of their Aftercare Plans. A supervision was completed on 10/20/2025 with case management staff and clinical staff by. The changes were added in section 10, in policy 709.54 B. |