INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection 6NEK6701 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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§ 717.20(a)(3) LICENSURE Resident Records
§ 717.20. Resident records.
(a) The licensee shall maintain an individual record for each resident which must include:
(3) Referrals to and from the drug and alcohol recovery house, if
applicable.
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Observations
Based on review of eight resident records the recovery house failed to maintain an individual record for each resident which must include: (3) Referrals to and from the drug and alcohol recovery house, if applicable.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Lead is responsible when conducting the intake within 24 hours to ask the resident what treatment facility/incarceration they came from and fill out the referral form as well as any referrals from BME to treatment. The Managers will continue to review resident files on the 1st of each month to make sure that the referral form is completed and signed. The new form will be created and disbursed on 08/15/2026.
The separate referral form will document other resources including the referrals for clothing, transportation, food, employment services, and how to locate a CRS. |
§ 717.22(b)(2)(iii) 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:
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
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Observations
Based on review of eight resident records the recovery house failed to complete the following documentation, which must be signed by the resident, within 24 hours of arrival: Resident orientation to the drug and alcohol recovery house which must include: (iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Leads conduct orientation to the house when the intake is completed within 24 hours of arrival. House Leads introduce new residents to other residents, provide them with a copy of our Program Standards (handbook) which are the rules for resident to follow, provide transportation to weekly house meetings, and conduct confidential one-on-one weekly program reviews where residents must provide meeting sheets and discuss residents' recovery program. Leads also inform new residents of where to find on the bulletin boards local resources for food, clothing, treatment, meetings, transportation, and CRS/CPS support. Resident will sign off on the Essential Services acknowledgement form that they were made aware of where this information is posted. The Manager is responsible that the Lead is ensuring this corrective action. This deficiency will be implemented on 08/15/2026.
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§ 717.26 LICENSURE Complaint management
§ 717.26. Complaint management.
The licensee shall develop and implement written policies and procedures for managing complaints from residents, family members and community members, which must include procedures for informing residents, family members and community members of the complaint process, including the ability to file a complaint with the Department.
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Observations
Based on reviews of seven resident records and the house rules, the recovery house failed to inform the residents of the complaint process, including the ability to file a complaint with the Department.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Director will add a line to the beginning of residency form of what our complaint process is and include the Departments phone number by 08/15/2026. The Director is responsible for ensuring the corrective action is implemented and will add the complaint process to the Program Standards (handbook) and include DDAP phone number. Managers will inspect resident files on the 1st of the month ensure that it does not happen again.
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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 one 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.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Leads are responsible for contacting the emergency contact within 12 hours after they leave the recovery house. Managers will review all resident files on the 1st of each month to ensure this policy is being followed.
The Director is responsible for ensuring the corrective action is implemented and will be completed by 8/15/2026.
When someone is discharged or leaves voluntarily the Lead is responsible to contact the emergency contact within 12 hours. The Director will always follow up with the Lead to ensure that this policy has been completed. |