INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 7WNK6701 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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§ 717.20(a)(3) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(3) Referrals to and from the drug and alcohol recovery house, if
applicable.
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Observations
Based on review of 7 resident records the recovery house failed to maintain an individual record for each resident which must include: (3) Referrals to and from the drug and alcohol recovery house, if
applicable.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Lead is responsible when conducting the intake to ask the resident what treatment/incarceration they came from and fill out the referral form as well as any referrals from BME to treatment. The Managers will continue to review resident files on the 1st of each month to make sure that the referral form is completed and signed. The new form will be created and disbursed on 08/15/2026.
The separate referral form will document other resources including the referrals for clothing, transportation, food, employment services, and how to locate a CRS. |
§ 717.22(b)(2)(iii) 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:
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
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Observations
Based on review of seven resident records the recovery house failed to complete the following documentation, which must be signed by the resident, within 24 hours of arrival: Resident orientation to the drug and alcohol recovery house which must include: (iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Lead's conduct orientation to the house when the intake is completed within 24 hours of arrival. House Lead's introduce new residents to other residents, provide them with a copy of our Program Standards which are the rules for resident to follow, provide transportation to weekly house meetings, and conduct confidential one-on-one weekly program reviews where residents must provide meeting sheets and discuss residents' recovery program. Leads also inform new resident information about local food banks and will provide new resident with a $25 gift card to Community Aid for clothing if needed. The Manager is responsible that the Lead is ensuring this corrective action. This deficiency will be implemented on 8/14/2026. |
§ 717.26 LICENSURE Complaint management
§ 717.26. Complaint management.
The licensee shall develop and implement written policies and procedures for managing complaints from residents, family members and community members, which must include procedures for informing residents, family members and community members of the complaint process, including the ability to file a complaint with the Department.
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Observations
Based on review of seven resident records and the house rules the recovery house failed to inform the residents of the of the complaint process, including the ability to file a complaint with the Department.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Director will add a line to the beg of residency form of that provides our complaint process and include the Departments phone number on the beginning of residency form. by 8/14/2026
The Director is responsible for ensuring the corrective action is implemented and will add to the Program Standards (handbook) what the complaint process is including DDAP phone number. Managers will inspect resident files on the 1st of the month to ensure that it does not happen again. |