INITIAL COMMENTS
|
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 LEF66701 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.
|
Plan of Correction
|
§ 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.
|
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
|
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 unwavering 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. |
§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on a review of the physical plant inspection the recovery house failed to ventilate toilet and wash room by exhaust fan or window.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
As of August 21, 2024, a proactive approach was taken by the director to address compliance issues within the property. A visit to Home Depot resulted in the purchase of all necessary lighting, ventilation, and exhaust fans required to bring the bathroom into full compliance with the standards set forth by DDAP. Furthermore, a skilled contractor was promptly hired to initiate the essential renovation work based on the on-site findings. The comprehensive renovation project is scheduled to be completed by September 13, 2024, and detailed photographic documentation will be submitted to provide a clear record of the improvements made. Looking ahead, the director is committed to maintaining a vigilant approach to compliance and property standards. Prior to DDAP's upcoming on-site inspection, the director will conduct a thorough walk-through of the property, leveraging a more discerning eye to ensure that every aspect is meticulously up to standard. This proactive measure will also involve printing out the DDAP plant standards and conducting a comprehensive walk-through with the house manager, ensuring that all are aligned and fully informed. Moreover, Bridgeway House has acknowledged the specific requirement for a window or exhaust fan in all bathrooms as per the DDAP standards. As a result, proactive steps will be taken to ensure that this essential requirement is fulfilled well in advance of all future inspections, thereby demonstrating a steadfast commitment to maintaining compliance and upholding the highest standards within the property. |
§ 717.30(d)(2) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen in addition to the fire extinguishers required under paragraph (1) . The extinguisher in the kitchen must be located near an exit and away from the cooking area.
|
Observations
Based on physical plant inspection the recovery house failed to have a fire extinguisher in the suite kitchen.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
As of August 29, 2024, the director took proactive steps by tasking the house manager with the installation of a portable fire extinguisher in the suite's kitchen, enhancing the safety measures within the property. On the same day, the fire department conducted a comprehensive inspection and duly approved all fire extinguishers, affirming their compliance with the essential ABC rating. Looking ahead, on September 10th, the director has scheduled a training session to educate the house manager on the precise locations where all fire extinguishers must be positioned in accordance with the exacting standards outlined by DDAP. Furthermore, a systematic approach has been established, wherein both the director and the house manager will conduct joint property walks every 30 days to meticulously verify that all fire extinguishers remain in optimal working condition and have not been relocated from their designated positions. In anticipation of next year's on-site inspection, the director is committed to ensuring a proactive and strategic approach to fire safety compliance. To this end, arrangements will be made to ensure that the fire department conducts a thorough inspection 60 days before the scheduled inspection. This proactive measure guarantees that all fire extinguishers are in optimal working order, have been meticulously inspected, and have obtained the essential ABC rating well before the inspection. By adopting this proactive approach, any potential issues with nonworking fire extinguishers can be addressed promptly, thereby mitigating the risk of last-minute compliance challenges. |
§ 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.
|
Observations
Based on a review of the fire extinguishers located throughout that property, the recovery house failed to have 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.
|
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, ensuring the property is fully prepared and compliant with all safety regulations well before the official inspection. |