INITIAL COMMENTS
|
This report is a result of an on-site renewal licensure inspection conducted on 09/08/2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection,113004 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.
|
Plan of Correction
|
§ 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.
|
Observations
Based on a review of resident records, the recovery house failed to have an individual record for each resident in the recovery house.
These findings were reviewed with the recovery house staff during the licensing process.
|
Plan of Correction
Moving forward, the Director will ensure that client records are kept electronically for a minimum of four years.
The Director has already implemented this as of June 2023. The corrections that have been made as of 9/11/2023 are added demographic information to the electronic census, changed the consent to say the resident received the orientation handbook and resident rights, corrected the end of residency form to be in compliance with DDAP regulations, and added an emergency contact log. The Director will contact a residents' emergency contact 12 hours after departure and again 7 days after.
The Director is responsible for ensuring this continues to happen.
This deficiency was corrected as of 9/11/2023. |
§ 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.
|
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.
|
Plan of Correction
As of 9/11/2023 the Director implemented recording basic personal information including demographic information on the resident census.
Upon a resident's intake, the Director will ask all pertinent questions to accurately record their demographic information including date of birth, clean date, drug of choice, drug and alcohol history, mental health diagnosis, primary doctor, allergies, ethnicity, origin county, and medications.
This was started on September 11, 2023, by the Director and will continue with every new intake. This same information will be saved on the departure census after a resident exits our program. This information will be kept for a minimum of four years and is solely the Director's responsibility. |
§ 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.
|
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.
|
Plan of Correction
Effective on 9/11/2023 the Director implemented end of residency forms, basic personal data, and emergency contact forms.
The director is solely responsible for contacting a resident's emergency contact with 12 hours of departure and again within 7 days.
The steps taken on 9/11/2023 were to correct the "Notification to an Emergency Contact" form to state (a) The licensee shall develop and implement written policies and procedures that specify the
methods and circumstances, including the resident's hospitalization or death, for notifying the
resident's emergency contact with the resident's consent. The resident may revoke their
consent to provide notice to the emergency contact, but must supply another emergency
contact.
(b) The licensee shall make at least one attempt to notify the resident's emergency contact
in accordance with subsection (a) immediately and in no event more than 12 hours after the
resident decides to end residency or does not return to the drug and alcohol recovery house as
expected. This subsection shall not apply if the licensee knows or has reason to know of
allegations of domestic abuse on the resident by the emergency contact.
The director will follow DDAP's regulations with every departure and record whether or not they were able to contact an emergency contact on both attempts. This was implemented on 9/11/2023. |