INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 3EY26701 Surge Recovery 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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§ 717.27 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 two of three applicable discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident # 6 was admitted on November 25, 2025, and discharged February 24, 2026. There was no notification to the emergency contact provided in the resident record.
Resident # 7 was admitted on November 6, 2025, and discharged February 24, 2026. There was no notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Facility Name: Surge Recovery
Regulation Cited: § 717.27 Notification to Family Member or Emergency Contact
Date of Inspection: 4/9/26
Prepared By: Managing Director
Deficiency Cited
Based on two of three applicable discharged resident records reviewed, the facility failed to provide notification to the resident's emergency contact regarding the resident's decision to end residency or failure to return to the recovery house as expected.
There were resident files that did not contain emergency contact information. These findings were reviewed with recovery house staff during the licensing process.
Corrective Action Taken
Upon notification of the deficiency, Surge Recovery immediately reviewed discharge and resident departure procedures related to emergency contact notification requirements.
Supervisory and direct care staff were retrained regarding the requirement to make at least one documented attempt to notify a resident's emergency contact, with resident consent, immediately and no later than twelve (12) hours after a resident decides to end residency or fails to return as expected.
Documentation procedures were reinforced to ensure all notification attempts are properly recorded in the resident file.
Systemic Corrective Action
To prevent recurrence of this deficiency, Surge Recovery has implemented the following corrective measures:
1. Policies and procedures regarding emergency contact notification have been reviewed and updated to ensure compliance with § 717.27.
2. A standardized Emergency Contact Notification Form and tracking process has been implemented to document:
o Date and time of notification attempt
o Method of contact
o Staff person completing the notification
o Outcome of the contact attempt
3. Resident consent regarding emergency contact notification will continue to be obtained during the admission process and maintained in the resident file.
4. All resident departures, discharges, AWOL incidents, or failures to return as expected will be immediately reviewed by supervisory staff to determine notification requirements and ensure completion within required timeframes.
5. Supervisory staff will conduct weekly audits of discharge and incident documentation to verify compliance with notification and documentation requirements.
6. Staff training regarding emergency contact notification requirements and documentation procedures will be completed during orientation and annually thereafter.
Date of Compliance
Surge Recovery expects full compliance with this corrective action plan by:
5/6/26 |
§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The water temperature in the bathroom reached a temperature of 135 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Effective immediately, the facility adjusted the hot water heater thermostat to ensure water temperatures remain at or below 120 degrees Fahrenheit in accordance with licensing and resident safety requirements. Water temperatures were re-checked following the adjustment to confirm compliance.
To prevent future occurrences, the Executive Director and designated maintenance staff will conduct and document routine monthly water temperature checks throughout the facility to ensure temperatures remain within the required safe range. Any temperature readings exceeding 120 degrees Fahrenheit will result in immediate corrective action, including adjustment of the water heater and follow-up monitoring.
In addition, maintenance and supervisory staff were informed of the regulatory requirement regarding maximum water temperatures during the licensing review process and will continue to receive ongoing instruction regarding physical plant safety standards and compliance expectations.
The facility will maintain documentation of all water temperature monitoring, maintenance activities, and corrective actions for review during future inspections. |
§ 717.30(d)(3) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection must be indicated on the extinguisher or inspection tag; the licensee shall replace or repair a fire extinguisher found to be inoperable within 48 hours.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. Extinguishers on second floor had tags that were expired.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Effective immediately, the facility contacted a licensed fire extinguisher service company to inspect and service all fire extinguishers within the recovery house. The extinguishers on the second floor were inspected, updated, and provided with current inspection tags to ensure compliance with annual inspection requirements.
To prevent future occurrences, the Executive Director and designated maintenance staff will conduct routine monthly safety inspections to verify that all fire extinguishers are present, properly mounted, fully charged, unobstructed, and maintained with current inspection tags. The facility will also maintain a tracking system to monitor annual inspection due dates and schedule servicing before expiration.
In addition, staff responsible for facility oversight and safety monitoring were informed of the regulatory requirement during the licensing review process and will continue to receive ongoing instruction regarding fire safety compliance and physical plant inspection standards.
The facility will maintain documentation of fire extinguisher inspections, servicing records, and monthly safety checks for review during future inspections. |