INITIAL COMMENTS
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This report is a result of an on-site renewal licensure inspection conducted on June 2, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, W4EI6701 79 Blueridge. Llc was found not to 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(b) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
(2) Resident orientation to the drug and alcohol recovery house which must include all of the following:
(i) Drug and alcohol recovery house rules, including a method to record residents ' expected return time to the drug and alcohol recovery house.
(ii) Fee schedule including any lease agreement.
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
(iv) Financial policies and procedures.
(v) The location of posted emergency procedures and contact information for the house manager and the Department.
(vi) Medication control and self-administration policies.
(3) Basic personal data including:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(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.
(v) Drug and alcohol history.
(vi) Medical contact information.
(vii) Emergency contact.
(4) Consent to residency.
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
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Observations
Based on one of seven resident records reviewed, the facility failed to provide in the resident record a completed basic personal data to include:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(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.
(v) Drug and alcohol history.
(vi) Medical contact information.
Resident # 3 was admitted on September 26, 2025, and was still active at the time of the inspection. The basic personal data information was not documented in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will ensure that all residents complete and sign all intake paperwork within 24 hours of arrival. They will also randomly double check to see that all paperwork is completed and correct. This will be done for all current residents by 6/12/2026. |
§ 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 # 5 was admitted on January 15, 2025, and was discharged February 1, 2026. There was no notification to the emergency contact provided in the resident record.
Resident # 7 was admitted on September 17, 2025, and was discharged September 23, 2025. 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
House Manager will check regularly to ensure that all emergency contacts are called at the time of a resident's discharge. House manager will also make sure the date, time and who was called is recorded on the form. House Manager will communicate to house leads that this is to be done for every discharge going forward. |
§ 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 bathroom had a water temperature of 153 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will notify maintenance that the water temperature needs to be adjusted and cannot exceed 120 degrees Fahrenheit. Maintenance will complete this by 6/12/2026 and will check regularly to ensure the correct water temperatures are maintained. |