INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection C47H6701 79 Blueridge. Llc 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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§ 717.23 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 2 resident discharge records 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
8/14/2024 : On 8/13/2024 Notification of decision to end residency was implemented. When the recovery house makes a decision to end residency a written notification will be provided to the resident and one will be maintained in residents record. It will also state resident has the right to ask for reconsideration. The house manager will monitor all discharge non compliance for this form on a biweekly basis |
§ 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.
Findings:
In 2 out of 2 resident discharge records the recovery house failed to notify the emergency contact within 12 hours of residents departure.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
8/14/2024: As of 8/13/2024 all clients emergency contacts will be notified immediately and in no event more than 12 hours after resident decides to end residency or does not return to the recovery house as expected. Manager will make sure it's documented with the date, time, and details of the conversation with
emergency contact including message left on voice mail in the event the emergency contact doesn't answer. Manager will try again within an hour to reach emergency contact in the event there's no answer. |
§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on the physical plant inspection the recovery house failed to ensure that stairways, halllways, and exit from rooms and from the drug and alcohol recovery house are obstructed.
Findings:
The bedroom window with the fire escape ladder on the second floor was obstructed by air conditioners.
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Plan of Correction
8/14/2024: On 7/18/2024 air conditioner was removed from fire ladder window and placed in adjacent window of bedroom without fire ladder. Manager will make sure all fire ladder windows remain unobstructed at all times. |