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, 35896701 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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? 717.22(b) 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:
(1) Disclosure to the resident of criteria for beginning and ending residency.
(2) Resident orientation to the drug and alcohol recovery house which must include all of the following:
(i) Drug and alcohol recovery house rules, including a method to record residents ' expected return time to the drug and alcohol recovery house.
(ii) Fee schedule including any lease agreement.
(iii) Supports provided by the drug and alcohol recovery house, as well as referrals to other essential services as needed.
(iv) Financial policies and procedures.
(v) The location of posted emergency procedures and contact information for the house manager and the Department.
(vi) Medication control and self-administration policies.
(3) Basic personal data including:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker and other medical conditions that the resident chooses to have in the house record.
(v) Drug and alcohol history.
(vi) Medical contact information.
(vii) Emergency contact.
(4) Consent to residency.
(5) Disclosure to the resident of the recovery house ' s policies and procedures for situations when recovery house staff may notify the resident ' s emergency contact.
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Observations
Based on one of seven resident records reviewed, the facility failed to provide in the resident record a completed basic personal data to include:
(i) Name.
(ii) Birth date.
(iii) Demographic information.
(iv) Medical information provided by the resident, including allergies, asthma, seizure disorder, diabetes, pacemaker and other medical conditions that the resident chooses to have in the house record.
(v) Drug and alcohol history.
(vi) Medical contact information.
Resident # 1 was admitted on November 26, 2025, and was still active at the time of the inspection. The basic personal data information was not documented 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 ensure that all residents complete and sign all intake paperwork within 24 hours of arrival. They will also randomly double check to see that all paperwork is completed and correct. House manager will also communicate to all house leads that this should be completed within 24 hours for all clients. |
§ 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 two of three discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident # 7 was admitted on September 6, 2025, and was discharged November 22, 2025. There was no documentation of an end to residency 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 see that all current and future clients have a decision to end residency form completed when needed. House manager will communicate to house leads that this should be done and check regularly to ensure they are completed. |
§ 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 three 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 1, 2025, and was discharged January 10, 2026. There was no notification to the emergency contact provided in the resident record.
Resident # 6 was admitted on January 6, 2026, and was discharged February 16, 2026. There was no notification to the emergency contact provided in the resident record.
Resident # 7 was admitted on September 6, 2025, and was discharged November 22, 2025. 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 Make sure that all emergency contact notifications are completed within 12 hours of discharge. There will also be a written record of the date, time and who was spoken to. House manager will also communicate to house leads that this should be done for all clients at the time of discharge.
House manager will continue to monitor that upon discharge emergency contact information is completed so this doesn't happen again. |