INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 23056701 Westminster Homes of Lehigh Valley 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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§ 717.23 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 review of the resident records it was determined that the recovery house failed to provide the residents with a notification of decision to end residency including the reason and timeframe for ending residency, providing the resident an opportunity to request reconsider a decision to end residency before the decision to end residency takes effect.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Corrective Action:
Westminster Homes of the Lehigh Valley has developed and implemented a standardized Notification of Decision to End Residency form that includes:
The specific reason(s) for ending residency.
The effective date and timeframe for discharge.
The resident's right to request reconsideration of the decision before the discharge becomes effective.
Documentation of the resident's receipt of the notice or documentation of attempts to provide the notice if the resident refuses to sign.
All current resident files have been reviewed to ensure compliance with this requirement, and staff have been retrained on the revised discharge procedure and documentation requirements.
Prevention of Recurrence:
To ensure this deficiency does not recur, Westminster Homes of the Lehigh Valley has revised its discharge policy to require that a written Notification of Decision to End Residency be completed and placed in the resident's file prior to any discharge, except where immediate action is permitted by applicable regulations. Staff will receive ongoing training during orientation and annual policy reviews regarding discharge procedures and resident rights. In addition, the Executive Director will conduct periodic audits of resident records to verify that all required discharge documentation is completed and maintained in accordance with licensing requirements. Any identified deficiencies will be addressed immediately through corrective coaching and additional staff training.
Responsible Person:
The Executive Director is responsible for ensuring that all corrective actions outlined in this Plan of Correction are fully implemented, monitored, and maintained on an ongoing basis.
Completion Date:
July 6, 2026 |
§ 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 with no documentation of time or date called.
These findings were reviewed with the recovery house staff during the licensing process
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Plan of Correction
Corrective Action:
Effective immediately, Westminster Homes of the Lehigh Valley has implemented a revised procedure requiring staff to make at least one documented attempt to notify the resident's designated emergency contact immediately, and no later than 12 hours after a resident voluntarily leaves the program or fails to return as expected. Staff will document the date, time, method of contact, the individual making the notification, and the outcome of the communication attempt in the resident's record using a standardized documentation form.
Prevention of Recurrence:
To ensure this deficiency does not recur, Westminster Homes of the Lehigh Valley has updated its resident discharge and absent resident procedures to include a mandatory emergency contact notification checklist. All staff have been trained on the requirement to complete and document emergency contact notifications within the required timeframe. The Executive Director will conduct periodic audits of resident records to verify compliance with documentation requirements and will provide additional training or corrective action if any deficiencies are identified.
Responsible Person:
The Executive Director is responsible for ensuring that all corrective actions are implemented, monitored, and maintained in accordance with DDAP licensing requirements.
Completion Date:
July 6, 2026 |
§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on the physical plant inspection the licensee failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
Findings: fire exits in bedrooms were obstructed and unable to be accessed
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Corrective Action:
Westminster Homes of the Lehigh Valley immediately removed all furniture and other items that were obstructing access to bedroom fire exits. Staff inspected all resident rooms and common areas to verify that all exits, hallways, stairways, and emergency egress routes were clear and fully accessible.
Prevention of Recurrence:
To ensure this deficiency does not recur, Westminster Homes of the Lehigh Valley has implemented a policy requiring staff to routinely inspect all emergency exits, hallways, stairways, and bedroom egress routes to ensure they remain free of obstructions. Staff have been instructed that furniture may not be moved or arranged in a manner that blocks access to any fire escape or emergency exit. Weekly house safety inspections will be completed and documented, with monthly supervisory inspections conducted to verify ongoing compliance. Any obstruction identified during an inspection will be corrected immediately.
Responsible Person:
The Executive Director is responsible for ensuring that these corrective actions are implemented, monitored, and maintained on an ongoing basis.
Completion Date:
July 6, 2026 |