INITIAL COMMENTS
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This report is a result of an renewal on-site licensure inspection conducted on January 7, 2026 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, QI5X6701 Blue Mountain Recovery was found to not be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing.
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Plan of Correction
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§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
The recovery house did not provide written notification of decision to end residency.
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Plan of Correction
I the House Manager/ Owner Updated End of Residence Form in Lease,
House Manager/ Owner Added steps to discharge process to ensure all incidents are documented correctly.
All future discharges will have
REASON FOR DISCHARGE
OUTCOME FOR DISCHARGE
Sign and Date and Time which I the House Manger will fill out.
Also I the House Manager placed Discharge Plan in the recovery house for Future Discharges will be documented correctly and notified.
This is the Discharge Plan that I the House Manager will be implementing.
1- House Manager will Document everything on End Of Residence form
2- Client is notified by House Manager of reason and outcome ( If Applicable)
3-Time of Discharge, Sign and date by House Manager
4- House Manager will Ask Client to Sign (If Applicable)
5- House Manager will Contact Emergency Contact, Log Time, Max 12hrs from time of Discharge
6- House Manager will Sign and Date
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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
The recovery house did not document attempts to notify family or emergency contact immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the recovery house as expected.
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Plan of Correction
I the House Manager Updated End of Residence form
I the House Manager Added a time of discharge also a Time of Contact for Emergency Contact. To ensure I the House Manager will be within the 12hr period to contact.
I the House Manager Added a Step Plan for Discharged Residents, that I the House Manager will have Posted in my Recovery Houses.
For all Future Residents being discharge I the House Manager will be documented Time of Discharge and Time EC was contacted and Outcome of Phone call
I the House Manager have posted Step Plan in all recovery House to avoid any future incidents
All Changes and Updated Forms were emailed to Kelsey Leach DDAP Licensing Specialist |