INITIAL COMMENTS
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This report is a result of an on-site renewal licensure inspection conducted on July 15-16, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, HH5F6701 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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§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of the house manager ' s personal record, the facility failed to provide documentation of the house manager completing a feedback form for the training completed for the 2024 training year.
Staff #1 was hired as the house manager on February 1, 2023, and was still in this position at the time of the inspection. There was no documentation of feedback forms training provided.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will implement a training feedback form and complete them after any trainings. The feedback form will be implemented by 7/31/2025 by the House manager for all staff to complete upon completion of any future trainings. Staff member #1 will complete a training feedback form to be placed in their file. |
§ 717.19(a)(1) LICENSURE Resident Rights
§ 717.19. Resident rights.
(a) The licensee shall develop and implement written policies and procedures on resident rights which must include:
(1) Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority.
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Observations
Based on seven of eight resident records reviewed, the facility failed to include the resident rights to include the verbiage that Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority in resident records # 1, 2, 3, 5, 6, 7, 8.
Resident record # 4 did not have documentation of the resident rights acknowledgement in the record.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House manager will update the current residents' rights section in the intake packet to sate the following: "Residents shall retain all civil rights that have not been specifically curtailed by separate judicial or administrative determination by the appropriate legal authority in records." by 7/31/2025 so that it is updated in all of our future intake packets for residents.
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§ 717.22(b)(2)(ii) 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:
(ii) Fee schedule including any lease agreement.
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Observations
Based on eight of eight resident records reviewed, the facility failed to include documentation of a fee schedule including any lease agreement 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 create a fee schedule that includes the description of the type of fee and the amount to be included in the intake packet that is given to residents upon arrival. This will be implemented by 7/31/2025. House Manager will also review and check all paperwork to ensure this deficiency doesn't continue to occur. |
§ 717.22(b)(4) 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:
(4) Consent to residency.
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Observations
Based on one of six resident records reviewed, the facility failed to provide a consent to residency which must be signed by the resident within 24 hours.
Resident # 4 was admitted on June 6, 2025, and was still active at the time of the inspection. There was not a consent to residency 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 check to ensure that every intake packet has all paperwork included and that they are completed within 24 hours of admission. House manager will communicate to House leads that all paperwork must be completed and double checked by them upon new residents' arrival. This will be completed by 7/31/2025. |
§ 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 four discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.
Resident # 6 was admitted on May 8, 2025, and discharged May 29, 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 utilize decision to end residency form and ensure that all residents have one completed in their file when residency is ended. House manager will also communicate this information to all house leads so that they are completing the forms with residents and putting them in their files. This will be completed by 7/31/2025. |
§ 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 four 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 # 6 was admitted on May 8, 2025, and discharged May 29, 2025. There was no notification to the emergency contact provided in the resident record.
Resident # 8 was admitted on February 21, 2025, and discharged June 10, 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 check regularly to ensure that all emergency contacts are called at the time of a resident's discharge. House manager will communicate to house leads that this is to be done for every discharge going forward by 7/31/2025. |
§ 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 in the upstairs bathroom was read at 137 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
House Manager will notify maintenance that the water temperature needs to be adjusted and stay below 120 degrees Fahrenheit. Maintenance will complete this by 7/31/2025. House manager will ensure that maintenance does a monthly check to ensure hot water temperature remains at 120 degrees. |