INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 09/08/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection,113005 and Bridgeway House was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. 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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§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff records, the recovery house failed to have staff complete the tuberculosis and sexually transmitted diseases training using a department approved curriculum within the first 90 days of hire in the staff record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Moving forward, BridgeWay House Director, will make sure all trainings are completed on time in regulations with DDAP.
House Manager will have these trainings completed by October 1. Furthermore, Director, will ensure each year the trainings are completed by any new and old staff members in accordance with DDAP regulations.
To ensure this happens, the Director will use orientation and training forms to ensure DDAP trainings are done within 90 days of start date. At the 45-day point, the Director will have a meeting with the House Manager to ensure the trainings will be done before the 90-day mark. |
§ 717.19(b) LICENSURE Resident Rights
§ 717.19. Resident rights.
(b) The licensee shall obtain written acknowledgement by residents that they have received notice of their rights.
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Observations
Based on a review of resident records, the recovery house failed to obtain written acknowledgement by residents stating they have received notice of their rights in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Moving forward, the men's program and the women's program will run as one entity and use the same admission paperwork including the orientation handbook which includes the Resident Rights. Director will ensure House Manager has all the correct admission paperwork.
Upon intake, the House Manager will review the orientation handbook which includes the resident rights and have the resident sign acknowledging they have received both.
The Director changed the paperwork and consents to be in compliance with DDAP standards on, 9/11/2023. This was given to the owner and the men's House Manager to start using effective 9/12/2023. |
§ 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 have a complete individual record for each resident in the recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Moving forward, the Director will ensure the House Manager obtains all required records upon resident intake. These records will include both consents, the signed handbook page stating they received the orientation handbook and resident rights, Bridgeway house rules and regulations, end of residency form, and records of contact with emergency contact 12 hours after departure and 7 days after. This paperwork was given to the house manager on 9/11/2023. These will be kept electronically on BridgeWay House's shared drive for four years in accordance with DDAP regulations.
To ensure this happens, the Director will sit with the house manager during the next week of intakes to make sure he understands and is using what needs to be included in the resident binder and how to properly conduct an intake.
If he does not follow through, he will be written up. After three write-ups for the same infraction, the house manager would be let go and the Director would take over doing intakes until a replacement was found. To avoid this from happening, the Director will thoroughly go through the correct paperwork for each resident's record and will monitor the house manager's intakes for the next week. This will be implemented on 9/14/2023 and completed by 9/21/2023. |
§ 717.20(a)(2) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(2) Consent to residency form.
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Observations
Based on a review of resident records, the recovery house failed to obtain written acknowledgement by residents that they are required to participate in treatment, self-help groups or other drug and alcohol recovery supports in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Moving forward, the Director will ensure House Manger will have every resident sign the Bridgeway House consent that says, "residents are required to participate in treatment, self-help groups or other drug and alcohol recovery supports while living at Bridgeway House."
This consent was emailed to the House Manager by the Director on 9/11/2023. The Director explicitly explained how important it is to have a resident sign this consent.
To ensure this is happening, the director will go over all new admission's paperwork from 9/11/2023-9/14/2023 on 9/15/2023. If any changes need to be made, all new admissions will be called to the office so the Director can properly show the house manager how to obtain all resident records so there won't be a problem moving forward.
This consent will be stored with all other required documents in the resident's binder. Upon their departure, it will be uploaded to the BridgeWay House shared drive and kept for a minimum of four years.
This is effective immediately, 9/12/2023. |
§ 717.22(b)(2)(i) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on a review of resident records, the recovery house failed to have resident orientation acknowledgement in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Moving forward, the Director will ensure the House Manger reads over the orientation handbook with every new intake. House Manager will have each new intake sign the orientation handbook stating they have received the handbook and resident rights.
House Manager will keep the signature page in the resident's binder and give the handbook and resident rights to the resident.
Upon departure, all paperwork will be uploaded to the shared drive and kept for a minimum of four years.
To ensure this is happening, the Director will make an on-site visit on 9/15/2023 to review all new admission paperwork from 9/11/2023-9/14/2023. If any changes need to be made, the Director will call down all new admissions and show the house manager how to properly admit a new client. The Director will continue reviewing the resident records over the next 90 days to ensure the house manager is accurately keeping track of the resident records in accordance with DDAP regulations.
This is effective immediately, 9/14/2023. |
§ 717.22(b)(3)(iii) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(3) Basic personal data including:
(iii) Demographic information.
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Observations
Based on a review of resident records, the recovery house failed to document all basic personal data including demographic information within 24 hours of arrival in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Moving forward, the Director will ensure House Manger records demographic data for all new admissions upon intake. This data will be recorded and stored on our resident census and will be kept for a minimum of four years.
To ensure this is happening, the Director will make an on-site visit on 9/15/2023 to review all new admission paperwork and demographic information from 9/11/2023-9/14/2023. If any changes need to be made, the Director will call down all new admissions and show the house manager how to properly admit a new client and record demographic information. The Director will continue reviewing the resident records over the next 90 days to ensure the house manager is accurately keeping track of the resident records and demographic data in accordance with DDAP regulations.
This is effective immediately, 9/14/2023 |
§ 717.22(b)(3)(vii) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(3) Basic personal data including:
(vii) Emergency contact.
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Observations
Based on a review of resident records, the recovery house failed to complete all basic personal data including emergency contact form within 24 hours of arrival in all resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 9/11/2023, the Director emailed the House Manger all basic personal data forms including emergency contact log form and notification to an emergency contact consent which must be signed by a new admission within 24 hours of arrival in all resident records.
To ensure this is happening, the Director will make an on-site visit on 9/15/2023 to review all new admission paperwork and emergency contact forms from 9/11/2023-9/14/2023. If any changes need to be made, the Director will call down all new admissions and show the house manager how to properly admit a new client and record emergency contact information. The Director will continue reviewing the resident records over the next 90 days to ensure the house manager is accurately keeping track of the resident records and emergency contact data in accordance with DDAP regulations. |