INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 7WNK6701 Blue Mountain Escape, Inc 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.
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Plan of Correction
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§ 717.22(a)(1) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(a) The licensee shall develop and implement written policies and procedures for beginning of residency which include:
(1) Residency criteria.
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Observations
Based on a review of resident records, the recovery house failed to have a complete client record. The recovery house failed to have the resident sign a disclosure of resident criteria for beginning and ending residency within 24 hours of arrival.
Findings:
In 7 out of 7 resident records the recovery house failed to have a signed disclosure of resident criteria for beginning and ending of residency within 24 hours of arrival.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 05/07/2024 each current resident signed a disclosure of resident criteria for the beginning and ending residency.
The House Manager has inserted this form into each new resident packet on 05/07/2024. The House Manager will review resident files each month to ensure house leads are completing the proper intake paperwork. |
§ 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.
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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.
Findings:
In 1 out of 4 resident discharge files 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.
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Plan of Correction
On 05/07/2024 the House Manager instructed all house leads to complete the final discharge form and provide the resident notification stating the decision to end residency.
The house manager will review the resident files monthly to ensure the final discharge form has been completed and signed by the discharged resident.
Date when implemented was 05/07/2024 |
§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(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 consent to provide notice to the 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.
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Observations
Based on a review of resident records, the recovery house failed to make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) 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.
In 2 out of 4 resident discharge files the recovery house failed to notify the emergency contact within 12 hours of residents departure or discharrge from the program.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 05/07/2024 the House Manager has instructed each house lead to contact the emergency contact that the resident has failed to return to the recovery house and /or decided to end their residency. The house lead will note that they contacted the emergency contact within 12 hours on the Contents of Residency form.
The House Manager will review resident files monthly to ensure that this process is completed. |
§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
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Observations
Based on the physical plant inspection the recovery house failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
Findings:
The bedroom window with the fire escape ladder on the second floor was obstructed by a bed and not accessible.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 05/09/2024 the House Manager instructed the house lead to remove the bed that was obstructing the fire escape ladder. Pictures were submitted to DDAP.
The House Manager will ensure that this will not happen again. |