INITIAL COMMENTS
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This report is a result of an on-site renewal licensure inspection conducted on June 2, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 180O6701 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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§ 717.27 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 August 28, 2025, and was discharged October 7, 2025. There was no notification to the emergency contact provided in the resident record.
Resident # 6 was admitted on January 7, 2026, and was discharged April 21, 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
House manager will communicate with house leads that all emergency contacts must be notified and documented on discharge paperwork upon residents discharge from the recovery house. House manager will monitor that all discharge paperwork is completed and emergency contact was notified and documented properly including on completion of program. |
§ 717.29(b)(3) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(3) Keep the drug and alcohol recovery house free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility failed to keep the drug and alcohol recovery house free of rodent and insect infestation. Roaches were observed in the kitchen.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will make sure that residents are doing their chores daily and contacted exterminator to spray for bugs (exterminator sprayed house on 6/10/2026). House manager bought roach traps to place in the kitchen of all the recovery houses.
House manager will inspect biweekly for any bugs in recovery houses as well as continue to have the exterminator come every 6 weeks and keep traps updated in recovery houses. |
§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide ventilation by exhaust fan or window in each bathroom. The half bathroom on the first floor and the bathroom on the second floor did not have a fan or window.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager contacted maintenance to put exhaust fans in both bathrooms one on the half bath first floor and one in the second-floor bathroom of the recovery house. Moving forward House Manager will make sure all bathrooms have working exhaust fans or window ventilation in the recovery houses. |