INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 5DDO6701 Blue Mountain Escape, Inc 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 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.
In 1 out of 3 unsuccessful 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
All House Leads are required to contact an emergency contact within 12 hours upon discharge. It will be reiterated at the management meeting tonight, 11/19/2024, and its importance. It is also on the House Lead SOP which they have been given a copy.
The client was discharged before the inspection date.
As noted, the House Lead is responsible. The House Manager will be reviewing all client files on a monthly basis.
This has been addressed with House Lead and House Manager.
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