INITIAL COMMENTS
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This report is a result of an on-site renewal licensure inspection conducted on July 15-16, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, YKLD6701 79 Blueridge. Llc was found not to 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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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the house manager ' s personal record, the facility failed to provide documentation of the house manager completing a feedback form for the training completed for the 2024 training year.
Staff #1 was hired as the house manager on February 1, 2023, and was still in this position at the time of the inspection. There was no documentation of feedback forms for completed training provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will implement a training feedback form and complete them after any trainings. The feedback form will be implemented by 7/31/2025 by the House manager for all staff to complete upon completion of any future trainings. |
§ 717.19(a)(1) LICENSURE Resident Rights
§ 717.19. Resident rights.
(a) The licensee shall develop and implement written policies and procedures on resident rights which must include:
(1) Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority.
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Observations
Based on six resident records reviewed, the facility failed to include the resident rights to include the verbiage that Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will update the current residents' rights section in the intake packet to sate the following: "Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority in records." by 7/31/2025 so that it is updated in all of our future intake packets for residents. |
§ 717.22(b)(2)(ii) 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:
(ii) Fee schedule including any lease agreement.
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Observations
Based on six of six resident records reviewed, the facility failed to include documentation of a fee schedule including any lease agreement in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will create a fee schedule that includes the description of the type of fee and the amount to be included in the intake packet that is given to residents upon arrival. This will be implemented by 7/31/2025. House Manager will also review and check all paperwork to ensure this deficiency doesn't continue to occur. |
§ 717.22(b)(4) 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:
(4) Consent to residency.
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Observations
Based on one of six resident records reviewed, the facility failed to provide a consent to residency which must be signed by the resident within 24 hours.
Resident #3 was admitted on May 27, 2025, and was still active at the time of the inspection. There was not a consent to residency provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will check to ensure that every intake packet has all paperwork included and that they are completed within 24 hours of admission. House manager will communicate to House leads that all paperwork must be completed and double checked by them upon new residents' arrival. This will be completed by 7/31/2025.
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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 one of two discharged resident records reviewed, the facility failed to provide notification to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.
Resident # 6 was admitted on July 11, 2024, and was discharged June 28, 2025. There was not a notification to the emergency contact provided in the resident record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will check regularly to ensure that all emergency contacts are called at the time of a resident's discharge. House manager will communicate to house leads that this is to be done for every discharge going forward by 7/31/2025. |
§ 717.29(b)(2) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(2) Store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents and remove all trash at least once each week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents. Trash cans outside the facility did not have lids covering them to prevent insects or rodents.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will check regularly to make sure every house has a trashcan and a lid. House manager will purchase lids and trashcans where needed by 7/31/2025. |
§ 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 a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed. The ladder designated for the emergency exit on the second floor was obstructed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will notify all residents to not obstruct fire ladder covers with items and post a visible sign stating the same by 7/31/2025. House Manager will also complete routine inspection to check if emergency fire ladder boxes are clear and free from obstruction. |