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, C47H6701 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)(3) LICENSURE Resident Rights
§ 717.19. Resident rights.
(a) The licensee shall develop and implement written policies and procedures on resident rights which must include:
(3) Residents have the right to inspect their own records.
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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 two 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 #5 was admitted on October 24, 2024, and discharged March 19, 2025. The required personal data was not in the resident record.
Resident #6 was admitted on April 7, 2025, and discharged May 23, 2025. 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. |
§ 717.27 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 one 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 October 24, 2024, and discharged March 19, 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 communicate to house leads that this is to be done for every discharge going forward by 7/31/2025. |
§ 717.29(b)(2) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(2) Store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents and remove all trash at least once each week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents. Trash cans outside the facility did not have lids covering them to prevent insects or rodents.
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 make sure every house has a trashcan and a lid. House manager will purchase lids and trashcans where needed by 7/31/2025. |
§ 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 was read at 148 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 stay below 120 degrees Fahrenheit. Maintenance will complete this by 7/31/2025. House manager will do monthly temperature checks with maintenance to ensure hot water temperature remains at 120 degrees.
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§ 717.29(e)(4) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There must be slip-resistant surfaces in all bathtubs and showers.
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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 bathroom in the basement 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(d)(1) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(1) Maintain at least one portable fire extinguisher with a minimum of an ABC rating for every 2,000 square feet of space and fraction of it on each floor.
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Observations
Based on a physical plant inspection, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating for every 2,000 square feet of space and fraction of it on each floor. There was not a fire extinguisher available on the second floor.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will purchase a fire extinguisher and have it tagged and inspected by 7/31/2025 so that there is one for every 2,000 square feet of space. House manager and house leads will check regularly to ensure that this happens. |