INITIAL COMMENTS
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This report is a result of an on-site renewal licensure inspection conducted on July 15-16, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, I80O6701 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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§ 717.18(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 house manager ' s personal record, the facility failed to provide documentation of the house manager completing a feedback form for the training completed for the 2024 training year.
Staff #1 was hired as the house manager on February 1, 2023, and was still in this position at the time of the inspection. There was no documentation of feedback forms training provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will implement a training feedback form and complete them after any trainings. The feedback form will be implemented by 7/31/2025 by the House manager for all staff to complete upon completion of any future trainings. |
§ 717.19(a)(1) LICENSURE Resident Rights
§ 717.19. Resident rights.
(a) The licensee shall develop and implement written policies and procedures on resident rights which must include:
(1) Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority.
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Observations
Based on seven resident records reviewed, the facility failed to include the resident rights to include the verbiage that Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority in records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will update the current residents' rights section in the intake packet to sate the following: "Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority in records." by 7/31/2025 so that it is updated in all of our future intake packets for residents. |
§ 717.22(b)(2)(ii) 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:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(ii) Fee schedule including any lease agreement.
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Observations
Based on seven resident records reviewed, the facility failed to include documentation of a fee schedule including any lease agreement 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 create a fee schedule that includes the description of the type of fee and the amount to be included in the intake packet that is given to residents upon arrival. This will be implemented by 7/31/2025. House Manager will also review and check all paperwork to ensure this deficiency doesn't continue to occur. |
? 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 documentation, signed by the resident within 24 hours of arrival, The resident ' s basic personal data is to include:
(i)Name
(ii)Birth Date
(iii)Demographic information
(iv)Medical Information
(v)Drug and alcohol history
(vi)Medical contact information
(vii)Emergency contact
Resident #1 was admitted on April 28, 2025, and is an active resident. The required personal data was not 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 7/31/2025. |
§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide ventilation by exhaust fan or window in each bathroom. The upstairs bathroom and the downstairs bathroom did not have an operable fan or window.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will notify Maintenace for the need of exhaust fans in all bathrooms without windows in them and request the completion of this by 7/31/2025 so that all bathrooms will have proper ventilation by that date. |
§ 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 a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed. The emergency exit on the third floor was obstructed and not accessible.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will notify all residents to not obstruct fire ladder covers with items and post a visible sign stating the same by 7/31/2025. House Manager will also complete routine inspection to check if emergency fire ladder boxes are clear and free from obstruction. |
§ 717.30(b)(3) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(3) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing. The railing at the top the stairs was loose and not secured.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will inform maintenance of the loose handrail at the top of the stairs and request for it to be fixed properly by 7/31/2025. House manager will complete routine checks of all property for new maintenace issues and stay in communication with house leads so they may notify her of any new repairs or issues so they can be addressed. |