Bridges Treatment Center

Non-compliance, DBHDS investigation : 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;

Individual #1 was left unattended in a cottage, when the remaining residents and staff members moved from the cottage setting to the gymnasium. Individual #1 was unattended for approximately 20-25 minutes before it was realized that they were not present in the gymnasium. Despite not having a formal written procedure for moving as a group from location to location on the campus, both Employee #1 and Employee #2 admitted that the internal procedure was not followed, resulting in Individual #1 being left unattended. The provider failed to demonstrate a structured program of care designed to provide protection, guidance and supervision.

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-270. B. (1) A person who assumes or is designated to assume the responsibilities of a position or any combination of positions described in this ...

At the time of the inspection, the job descriptions for Employee #1 and Employee #2 included the requirement for a bachelor's degree in a human service field. Evidence of the completion of a bachelor's degree in a human services field was not found in the personnel records for Employee #1 and Employee #2. The provider failed to ensure that persons assuming the responsibilities of a position shall meet the qualifications of the position.

Non-compliance, DBHDS investigation : 12VAC35-46-800. A. (1) There shall be evidence of a structured program of care designed to: 1. Meet the residents' physical and emotional needs;

Individual #1 was able to obtain Medication #1 and Medication #2 from Individual #2 reportedly 'cheeking' their medication and bringing the medication back to the shared room. Individual #1 was able to obtain Medication #3 by hiding them in their belongings after using a community pass with Entity #1. These medications were found in the possession of Individual #1 as a result of a room check. The provider failed to implement a structured program of care designed to meet the residents' physical and emotional needs.

Non-compliance, DBHDS investigation : 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;

Individual #1 was able to obtain Medication #1 and Medication #2 from Individual #2 reportedly 'cheeking' their medication and bringing the medication back to the shared room. Individual #1 was able to obtain Medication #3 by hiding them in their belongings after using a community pass with Entity #1. These medications were found in the possession of Individual #1 as a result of a room check. The provider failed to implement a structured program of care designed to provide protection, guidance and supervision.

Non-compliance, DBHDS investigation : 12VAC35-46-70. Each provider shall guarantee resident rights as outlined in § 37.2-400 of the Code of Virginia and in the Rules and Regulations to Assure the ...

Please see the citations issued by the Office of Human Rights, below.

Non-compliance, DBHDS investigation : 12VAC35-46-800. A. (1) There shall be evidence of a structured program of care designed to: 1. Meet the residents' physical and emotional needs;

Based on the provider's internal investigative findings, the disposition of Entity #2 and the action taken by Entity #3, the conduct of Employee #1 did not meet the physical and emotional needs of Individual #1. The provider failed to meet the residents' physical and emotional needs.

Non-compliance, DBHDS investigation : 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;

Based on the provider's internal investigative findings, the disposition of Entity #2 and the action taken by Entity #3, the conduct of Employee #1 did not provide protection, guidance and supervision for Individual #1. The provider failed to provide protection, guidance and supervision of residents served.

Non-compliance, DBHDS investigation : 12VAC35-46-920. (5) The following actions are prohibited: 5. Any action that is humiliating, degrading, or abusive;

Based on the provider's internal investigative findings, the disposition of Entity #2 and the action taken by Entity #3, the conduct of Employee #1 was humiliating, degrading and abusive to Individual #1. The provider failed to prevent any action that is humiliating, degrading or abusive.

Non-compliance, DBHDS investigation : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

CHRIS A#20240016/Incident date: October 6, 2024 "Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. • Individual #1 reported the following: ◦ Employee #1 "groomed" Individual #1 by first leaving notes for Individual #1 then hugging, kissing, touching Individual #1 above and under clothing while Individual #1 was receiving services. ◦ Employee #1 engaged in oral sexual encounter with Individual #1. • During investigation, it was revealed on phone call logs that Employee #1 and Individual #1 had multiple calls/texts back and forth between each other that included times when Individual #1 was off campus on a home pass. • Entity #2 informed Human Rights Advocate via letter dated October 31, 2024, that it was determined the disposition was Founded, Level One, for Sexual Abuse. • Entity #2 reported to Human Rights Advocate that Employee #1 was charged with 7 felony counts of VA Code 18.2-370.1, Taking Indecent Liberties with Child by Person in Custodial or Supervisory Relationships. Employee #1's actions toward ...

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. CHRIS A#20230018, A#20230019, A#20230020, A#20230021, A#20230022, A#20230023, A#20230024, A#20230025, A#20230026, A#20230027, and A#20230028/Incident Date 6.17.23 Provider has substantiated for neglect based on the following: • On 6/17/23, Employee #1 took Individual #1, Individual #2, Individual #3, Individual #4, and Individual #5 out into the community. • During interviews Individual #1, Individual #2, Individual #3, Individual #4, and Individual #5 all reported that Employee #1 stopped at their home and went inside for a period of time (all individuals reported around 15-20 minutes), leaving Individual #1, Individual #2, Individual #3, Individual #4, and Individual #5 in the vehicle unattended. • Individual #2 and Individual #3 reported that while Employee #1 was in Employee #1's home leaving all individuals unattended, that Individual #1 and Individual #4 kissed. • Employee #1 took Individual #1, Individual #2, Individual #3, Individual #4, and Individual #5 to the local park for a community event and failed to provide adequate supervision by allowing ...

Non-compliance, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

CHRIS Number: 20230083 Date/Time of Discover: 06/06/2023 7:10PM Enter Date/Time: 06/08/2023 2:20PM Reporting Delay: 19:10:00 Location Name: Bridges Treatment Center CHRIS Number: 20230095 Date/Time of Discover: 06/17/2023 5:45PM Enter Date/Time: 06/18/2023 6:49PM Reporting Delay: 1:4:00 Location Name: Bridges Treatment Center CHRIS Number: 20230096 Date/Time of Discover: 06/17/2023 5:45PM Enter Date/Time: 06/18/2023 7:00PM Reporting Delay: 1:15:00 Location Name: Bridges Treatment Center CHRIS Number: 20230097 Date/Time of Discover: 06/17/2023 5:45PM Enter Date/Time: 06/18/2023 7:06PM Reporting Delay: 1:21:00 Location Name: Bridges Treatment Center

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. CHRIS A#20230012/Incident Date 6.01.23 Provider has substantiated for neglect based on the following: • After a community outing on 5/29/23, Employee #1 reported that a vape that was their pocketbook was missing. • On 6/1/23, peers of Individual #1 reported that Individual #1 was in possession of a vape. • Vape was found in Individual #1's room after a room search was conducted, which was the vape that belonged to Employee #1 that went missing on 5/29/23. • It is against provider policy for any employee to have a vape with them while working with individual. Employee #1's failure to follow provider policy allowed Individual #1 an opportunity to become in possession of the vape and is a violation of 12VAC35-115-50(B)(2).

Non-compliance, DBHDS investigation : 12VAC35-46-310. A. (1) Required initial training: 1. Within seven days following their begin date, each staff member responsible for supervision of children ...

On the day of the inspection, Staff # 1 was found to be out of compliance with Provider's behavioral management training. Staff # 1 had previously worked for Provider when Mandt was offered, but was not re-trained upon re-hire when Provider switched to CPI..

Non-compliance, DBHDS investigation : 12VAC35-46-70. Each provider shall guarantee resident rights as outlined in § 37.2-400 of the Code of Virginia and in the Rules and Regulations to Assure the ...

Please see citations below by Office of Human Rights.

Non-compliance, DBHDS investigation : 12VAC35-115-100. A. (2) From admission until discharge from a service, each individual is entitled to: 2. Receive services in that setting and under those ...

• While reviewing the provider's internal SIR reports, the staff documented Individual #2 began exhibiting behaviors after staff denied the individual a second snack on 9/8/22. • Denial of food is a restriction of the individual's right to freedoms of everyday life unless such restriction is part of an individualized diet program and documented in the individual's ISP.

Non-compliance, DBHDS investigation : 12VAC35-115-110. A. Each individual is entitled to be completely free from any unnecessary use of seclusion, restraint, or time out.

"Seclusion" means the involuntary placement of an individual alone in an area secured by a door that is locked or held shut by a staff person, by physically blocking the door, or by any other physical or verbal means, so that the individual cannot leave it. CHRIS Abuse #20220011/Incident Date: 8.31.22 • During an onsite visit with provider as part of review of anonymous complaints made, individuals and staff were interviewed. Individual #1, along with another individual and staff reported the following during the interview discussion about use of the timeout room/area: ◦ Staff have escorted individuals to the timeout room and sometimes stand in the doorway to prevent individuals from leaving the area. ◦ Staff escorted individuals to the timeout room and sometimes closed the door and prevented individuals from trying to open the door by placing their foot at the bottom of the door and hand near the door handle. ◦ Individual #1 confirmed that the door to the timeout area has been closed while Individual #1 was in the timeout area. Staff were on the other side of the door, preventing Individual #1 from leaving the area. ◦ Provider has substantiated for the unauthorized use of seclusion.

Non-compliance, DBHDS investigation : 12VAC35-115-110. C. (4) The provider's duties. 4. Providers shall not use seclusion, restraint, or time out as a punishment or reprisal or for the convenience ...

• While reviewing the provider's internal SIR reports, the staff documented that Individual #2 was escorted to the time out room following verbal threats on 9/7/22. • The provider reported that the decision to escort Individual #2 to the time out room was determined based on a known history of peer-on-peer aggressions (9 SIR related incidents). • Individual #2's verbal threats and history of aggression do not allow for an assumption of imminent risk to self or others. • Providers shall not use timeout as a punishment; therefore, escorting Individual #2 to the time out room following verbal threats and based on a known history of aggressions, is a violation of 12VAC35- 115-110(C)(4).

Non-compliance, DBHDS investigation : 12VAC35-115-60. B. (4b) - The provider's duties. 4. Providers shall assign a specific person or group of persons to carry out each of the following activities ...

• While reviewing the provider's internal SIR reports, it was discovered that Individual #2 had a known history of peer-to-peer aggressions (9 SIR related incidents). • The provider utilized the time out room to address Individual #2's aggressive behavior, but failed to document this behavioral intervention in the ISP or on a behavioral treatment plan to address the behaviors.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3a) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

CHRIS A#20220022/Incident date 10.05.22 • Investigative findings were due for completion in the investigation tab in CHRIS on 10/20/22; however, the findings were not completed in CHRIS until 11/11/22. • Provider failed to complete investigative findings in CHRIS within 10 working days from the date the investigation began which is a violation of 12VAC35- 115-230(A)(3)(a).