INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection LGDC6701 Sarah J. Bentley Recovery House 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 two of three discharged resident records reviewed, the facility failed to provide written notification to the resident stating the decision to end residency.Resident # 2 was admitted on January 4, 2026, and an unknown discharge date. There was no documentation of an end to residency in the resident record.Resident # 3 was admitted on April 1, 2026, and an unknown discharge date. 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
1. A Discharge Summary was created and implemented in all Resident's Charts on Augst 20, 2026.
2. Project Director will monitor and ensure that all Residents sign the Discharge Summary prior to discharge (if applicable). |
§ 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 two 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 # 2 was admitted on January 4, 2026, and an unknown discharge date. There was no notification to the emergency contact provided in the resident record.Resident # 3 was admitted on April 1, 2026, and an unknown discharge date. 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
1. A Discharge Summary was created and implemented in all Resident's Charts on August 20, 2026. The Discharge Summary includes documentation which identifies the Emergency Contact, date, time and results by Staff.
2. Project Director will monitor and ensure that the Emergency Contact (as identified by the Resident) will be contacted within 8 hours.
3. The Project Director will conduct a quarterly chart audit to ensure that all resident discharge summaries are documented and completed to maintain compliance. |