INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection E8UK6701 Surge Recovery 2 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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§ 717.27 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 two of three applicable 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 # 5 was admitted on December 11, 2025, and discharged January 26, 2026. There was no notification to the emergency contact provided in the resident record.
Resident # 7 was admitted on December 30, 2025, and discharged February 19, 2026. There was no 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
Facility Name: Surge Recovery
Regulation Cited: § 717.27 Notification to Family Member or Emergency Contact
Date of Inspection: 4/9/26
Prepared By: Managing Director
Deficiency Cited
Based on two of three applicable discharged resident records reviewed, the facility failed to provide notification to the resident's emergency contact regarding the resident's decision to end residency or failure to return to the recovery house as expected.
There were resident files that did not contain emergency contact information. These findings were reviewed with recovery house staff during the licensing process.
Corrective Action Taken
Upon notification of the deficiency, Surge Recovery immediately reviewed discharge and resident departure procedures related to emergency contact notification requirements.
Supervisory and direct care staff were retrained regarding the requirement to make at least one documented attempt to notify a resident's emergency contact, with resident consent, immediately and no later than twelve (12) hours after a resident decides to end residency or fails to return as expected.
Documentation procedures were reinforced to ensure all notification attempts are properly recorded in the resident file.
Systemic Corrective Action
To prevent recurrence of this deficiency, Surge Recovery has implemented the following corrective measures:
1. Policies and procedures regarding emergency contact notification have been reviewed and updated to ensure compliance with § 717.27.
2. A standardized Emergency Contact Notification Form and tracking process has been implemented to document:
o Date and time of notification attempt
o Method of contact
o Staff person completing the notification
o Outcome of the contact attempt
3. Resident consent regarding emergency contact notification will continue to be obtained during the admission process and maintained in the resident file.
4. All resident departures, discharges, AWOL incidents, or failures to return as expected will be immediately reviewed by supervisory staff to determine notification requirements and ensure completion within required timeframes.
5. Supervisory staff will conduct weekly audits of discharge and incident documentation to verify compliance with notification and documentation requirements.
6. Staff training regarding emergency contact notification requirements and documentation procedures will be completed during orientation and annually thereafter.
Date of Compliance
Surge Recovery expects full compliance with this corrective action plan by:
5/6/26
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§ 717.29(d)(1)(v)(C) LICENSURE Physical plant standards - Sleep accomodation
§ 717.29. Physical plant standards.
(d) Sleeping accommodations.
(1) Each drug and alcohol recovery house bedroom must have the following:
(v) At least 50 square feet of floor space per resident measured wall to wall in each shared bedroom with bunk beds. Bunk beds must:
(C) Be equipped with securely attached railings on each open side and open end of the bunk.
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Observations
Based on a physical plant inspection, the facility failed to provide a bunk bed with securely attached railing on each open side of the bunk. Room # 2 has a bunk bed with no railing.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Plan of Correction
The facility acknowledges the finding that Room #2 contained a bunk bed without a securely attached safety railing on the open side of the bunk bed.
Effective immediately, the bunk bed in Room #2 was removed from use until corrective action could be completed. A properly secured safety railing was installed on the open side of the bunk bed to ensure compliance with physical plant and resident safety requirements.
To prevent future occurrences, the Executive Director and designated maintenance staff will conduct routine monthly inspections of all resident rooms and furniture to ensure bunk beds maintain securely attached railings on all open sides and remain in safe operating condition. Any deficiencies identified during inspections will be corrected immediately.
In addition, staff responsible for facility oversight and maintenance were informed of the requirement during the licensing review process and will continue to receive ongoing instruction regarding physical plant safety standards and compliance expectations.
The facility will maintain documentation of inspections, repairs, and corrective actions for review during future inspections. |
§ 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 ' s records, an incident involving medical personnel being called to the facility was not reported to the department within three business days after the incident occurred.
Resident #5 was admitted on December 11, 2025, and discharged January 26, 2026. An unusual incident requiring medical personnel presence occurred and an unusual incident report was not filed with the department within 3 days.
Resident # 7 was admitted on December 30, 2025, and discharged February 19, 2026. An unusual incident requiring medical personnel presence occurred and an unusual incident report was not filed with the department within 3 days.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Based on a review of resident records, incidents involving medical personnel being called to the facility were not reported to the Department within three (3) business days after the incidents occurred.
- Resident #5 was admitted on December 11, 2025, and discharged on January 26, 2026. An unusual incident requiring medical personnel presence occurred; however, an unusual incident report was not filed with the Department within the required three-business-day timeframe.
- Resident #7 was admitted on December 30, 2025, and discharged on February 19, 2026. An unusual incident requiring medical personnel presence occurred; however, an unusual incident report was not filed with the Department within the required three-business-day timeframe.
These findings were reviewed with recovery house staff during the licensing process.
Corrective Action Taken
Upon notification of the deficiency, Surge Recovery immediately reviewed the incidents involving Residents #5 and #7 and completed the required unusual incident documentation. Incident reports were submitted to the Department upon discovery of the oversight.
Supervisory and direct care staff responsible for incident reporting were retrained regarding Department reporting requirements, including mandatory reporting timelines for incidents involving emergency medical personnel.
Systemic Corrective Action
To prevent recurrence of this deficiency, Surge Recovery has implemented the following corrective measures:
1. An Incident Reporting Tracking Log has been established to monitor all unusual incidents and ensure reports are submitted to the Department within required timeframes.
2. Policies and procedures regarding unusual incident reporting have been reviewed and reinforced with all staff.
3. All incidents involving emergency medical services, hospitalization, overdose, injury, police involvement, or other reportable events will be immediately reviewed by supervisory staff to determine reporting obligations.
4. The Executive Director or designated supervisor will review all unusual incidents within twenty-four (24) hours to ensure timely completion and submission of required reports.
5. Staff training on incident reporting requirements, timelines, and documentation procedures will be conducted during orientation and annually thereafter.
6. Quarterly internal audits of incident reports and resident records will be conducted to monitor ongoing compliance with Department reporting requirements.
Date of Compliance
Surge Recovery expects full compliance with this corrective action plan by:
5/6/26
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