INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 50PG6701 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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§ 717.22(a)(1) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(a) The licensee shall develop and implement written policies and procedures for beginning of residency which include:
(1) Residency criteria.
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Observations
Based on a review of resident records, the recovery house failed to have a complete client record. The recovery house failed to have the resident sign a disclosure of resident criteria for beginning and ending residency within 24 hours of arrival.
Findings:
In 7 out of 7 resident records the recovery house failed to have a signed disclosure of resident criteria for beginning and ending of residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 05/07/2024 each current resident signed a disclosure of resident criteria for the beginning and ending of residency.
The House Manager has inserted this form into each new resident packet on 05/07/2024.
The House Manager will review resident files each month to ensure house leads are completing the proper paperwork. |
§ 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
Based on a review of resident records, the recovery house failed to provide a written notification to the resident stating the decision to end residency,
Findings:
In 2 out of 3 resident discharge files the recovery house failed to provide a written notification to the resident stating the decision to end residency.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 05/07/2024 the House Manager instructed all house leads to complete the final discharge form and provide the resident notification stating the decision to end residency.
The house manager will review the resident files monthly to ensure the final discharge form has been completed and signed by the discharged resident. |
§ 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.
Findings:
In 3 out of 3 resident discharge files the recovery house failed to notify the emergency contact within 12 hours of hospitilization and residents departure.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
On 05/15/2024 the House Manager has instructed each house lead to contact the emergency contact within 12 hours that the resident failed to return to the recovery house and/or decided to end their residency. The house lead will note that they contacted the emergency contact within 12 hours on the Contents of Residency form.
The House Manager will review each resident's file monthly to ensure that proper paperwork is completed by the house lead.
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§ 717.31(c)(4) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(4) An event at the drug and alcohol recovery house requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of resident records the recovery house failed to file a unusual incident report to the Department within 3 days of an event that resulted in the presence of police, fire or ambulance personnel.
Findings:
The presence of police was required and there is no incident report filed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
On 05/09/2024 the House Manager completed an unusual incident report regarding a resident that occurred on 04/30/2024. This incident involved police being called to the residence for vandalism of the property.
The House Manager will ensure to submit unusual incident reports to DDAP within 3 days of the incident. |