INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 7WNK6701 Blue Mountain Escape 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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§ 717.12 LICENSURE Refusal or revocation of license
§ 717.12. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the
Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the drug and alcohol recovery house.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or
attempting to obtain a license.
(6) Lending, borrowing or using the license of another drug and alcohol recovery house.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing residents at the drug and alcohol recovery house.
(9) Continued noncompliance in disregard of this part.
(10) Operating a drug and alcohol recovery house that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the applicant or licensee by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the drug and alcohol recovery house to correct deficiencies.
(c) If the drug and alcohol recovery house does not correct the deficiencies within the specified time, the Department will officially notify the applicant or licensee that it shall show cause why its license should not be denied or revoked under 1 Pa. Code § 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. The applicant or licensee shall file a written request within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code § 35.14.
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Observations
Based on a review of resident records the recovery house failed to comply with a plan of correction approved by the Department.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
A new resident intake form was implemented in February which ensures all required data collection by DDAP is listed. The steps that will be performed to ensure this deficiency is all Lead's have been informed that all questions asked on the form must have an answer. The Lead is responsible for ensuring the corrective action is implemented. On July 13, 2025 a meeting was conducted and all Lead's have been instructed. Around the 1st of the month the House Manager will review all client files to ensure this process is being followed. |
§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the staff training records the recovery house failed to follow recovery house training policy regarding an assessment of training needs for each staff person and volunteer, plan for addressing those needs and a mechanism to collect feedback on completed trainings.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Steps to ensure deficiency does not recur is a training log will be implemented, that indicates the dates of the required trainings, and the 6 hrs. of additional training. It will also indicate the assessment and feedback as to if the trainings was informative and did it meet the goals. The person who is responsible for ensuring the corrective action will be Stacy Nazay.
The corrective action has been completed on 7/3/2025.
Addressing the deficiency is that we did not provide the training needs assessment for each staff member and a mechanism for feedback for the completed trainings at the time of renewal. This will not occur again, and the training plan will be presented going forward at the time of the renewal. |
§ 717.18(b) LICENSURE Training
§ 717.18. Training.
(b) The licensee shall conduct and document an evaluation of the training plan annually.
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Observations
Based on a review of the staff training records the recovery house failed to provide an evaluation of the training plan annually.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
An evaluation of the training plan will involve the Director ensuring their training program is effective, efficient, and is meeting the needs of both the organization and DDAP requirements. The training plan will incorporate the training log and the participants input. The training duration will be every 6 months, and ongoing. The Director will ensure the corrective action is implemented beginning 7/3/2025. |
§ 717.18(c)(1) 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:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of the staff training records the recovery house failed to an updated training plan.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The facility will take steps to ensure the deficiency does not recur by submitting to the DDAP official the training plan at the next renewal, in June 2026. The person responsible will be Stacy Nazay. |
§ 717.18(c)(2) 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:
(2) First aid training, including training on overdose reversal medication.
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Observations
Based on a review of the staff training records the recovery house failed to provide a copy of the first aid training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
First Aid training was completed in July 2023, and the certificates were submitted on July 3, 2025. The person responsible for the corrective action is Stacy Nazay. |
§ 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 the staff training records the recovery house failed to provide HIV/AIDS, tuberculosis and sexually transmitted diseases training using a department approved curriculum.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All current certificates were submitted on July 3, 2025. These trainings will be done annually and will be entered into the training log with date. The person responsible for the corrective action is Stacy Nazay and the date it has been completed is 7/6/2025.
Addressing the deficiency was that we failed to provide the HIV/AIDS, tuberculosis and STD certificates to the DDAP official. Moving forward all certificates will be provided at the next renewal. |
§ 717.22(b)(3)(iv) 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:
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker, and other medical conditions that the resident chooses to have in the house record.
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Observations
Based on review of the resident records, the recovery house failed to collect medical provider information in 3 out of 6 records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Doctor and phone number is on the intake record and was not written in. The corrective measure was a new intake record form was created in February 2025 that makes the form simpler and comprehensible.
The Leads are responsible for completing the forms, and the House Manager will review all intake records at the beginning of the months to ensure this deficiency does not recur. The person responsible for the corrective action is Stacy Nazay. |
§ 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 in 3 out of 4 discharge records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Additional quarterly paperwork training with Leads will be done quarterly. Review of resident records will be completed monthly by House Manager. The date corrective action has been completed on July 6, 2025. |
§ 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 notify the emergency contact in 3 out of 4 unsuccessful discharge records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Additional quarterly paperwork training with Leads. House Manager will review all resident files the beginning of each month. The corrective action has been completed on July 6, 2025. All discharge paperwork is now to be emailed to the director to ensure compliance once a resident's emergency contact has been called. |