INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection DTQV6701 Keep It Green 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 one of three discharged resident records reviewed, the facility failed to provide 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
Current and any new Office Managers will be coached on which instances require notification as well as the proper documentation. Residents that move without notice or forwarding address will have a notice filled out and a copy will be sent to emergency contact as well as entered in their file. In the event an address is unavailable, staff will discuss with emergency contact during that notification process and mail a copy to the address furnished at that time.
The Director of Operations will be responsible to check discharged resident files for documentation prior to placing each discharged resident file in inactive clients. The Director of Operations will also audit all discharged files monthly to ensure no files have been missed.
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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 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All office staff will be coached on proper family member/emergency contact notification procedure and documentation. The staff member handling the discharge will notify the family or emergency contact of any incident no later than 12 hours after the event and document doing so in the resident's noted selection of the resident file. If a resident has withheld consent to notify the staff member handling the discharge will document that consent has been withheld.
The Director of Operations will be responsible to check discharged resident files for documentation prior to placing each discharged resident file in inactive clients. The Director of Operations will also audit all discharged files monthly to ensure no files have been missed.
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§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The water temperature was read at 141 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Staff has lowered the temperature of the water heater to less than or equal to 120°F.
The Director of Operations will monitor water temperature during weekly walkthroughs using a thermocouple. Any temperature readings greater than 120°F will immediately be reported to the Facility Director and the Facility Owner.
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§ 717.30(b)(2) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(2) Maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. Equipment such as ladders and escapes located above the ground floor must be securely affixed to the house. Rooms, including resident bedrooms, that contain an exit must be unlocked and accessible to all residents in the event of an emergency.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of two unobstructed exits that are separated by a minimum distance of 15 feet on every floor that contains resident bedrooms. The ladder designated for the emergency exit was covered by a bed and obstructed from use.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
All furniture has been moved back to its original positioning and no longer blocks the fire ladders.
The Director of Operations will monitor for any future moving of furniture during weekly walkthroughs and correct any blocked exits immediately. Residents are informed upon admission not to move furniture in their rooms and it will be included with house meeting notes monthly to remind all residents of the need to keep all furniture in its original positioning.
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