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, W4EI6701 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(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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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. |
§ 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 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 records.
Also, Resident record # 3 and # 7 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. |
§ 717.21(a) LICENSURE Resident Roster
§ 717.21. Resident roster.
(a) The licensee shall maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
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Observations
Based on one of seven resident records reviewed, the facility failed to maintain a resident roster that identifies the date of each resident ' s beginning and end or completion of residency.
Resident #4 was admitted on March 3, 2025, with an unknown discharge date. Resident # 4 was not documented on the resident roster provided by the facility.
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 client roster routinely with intake dates and discharge dates. Client roster will also be randomly double checked to ensure all the information is accurate and correct. This will be done for all current residents by 7/31/2025. |
§ 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 seven 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) 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 two of seven resident records reviewed, the facility failed to provide documentation, signed by the resident within 24 hours of arrival, The resident ' s basic personal data is to include:
(i)Name
(ii)Birth Date
(iii)Demographic information
(iv)Medical Information
(v)Drug and alcohol history
(vi)Medical contact information
(vii)Emergency contact
Resident #1 was admitted on July 10, 2025, and is an active resident. The required personal data was not in the resident record.
Resident #4 was admitted on March 3, 2025, with an unknown discharge date. The required personal data was not 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. This will be done for all current residents 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 two of four discharged resident records reviewed, the facility failed to provide written notification to the residents stating the decision to end residency.
Resident # 4 was admitted on March 3, 2025, with an unknown discharge date. There was no documentation of an end to residency in the resident record.
Resident # 5 was admitted on December 12, 2024, and discharged March 13, 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 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. |
§ 717.27 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 #4 was admitted on March 3, 2025, with an unknown discharge date. There was no notification to the emergency contact provided in the resident record.
Resident # 5 was admitted on May 5, 2025, and discharged June 21, 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(b)(2) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(2) Store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents and remove all trash at least once each week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash in noncombustible, covered containers that prevent the penetration of insects and rodents. Trash cans outside the facility did not have lids covering them to prevent insects or rodents.
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 make sure every house has a trashcan and a lid. House manager will purchase lids and trashcans where needed 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 149 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 check monthly with maintenance that water temperature remains at 120 degrees.
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§ 717.30(b)(1) LICENSURE Safety and emergency procedures - Exits
§ 717.30. Safety and emergency procedures.
(b) Exits. The licensee shall:
(1) Ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the drug and alcohol recovery house are unobstructed. The back door of the house was difficult to open because of the floor being raised and the door sticking.
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 about fixing the back door, so it does not stick. This will be completed by 7/31/2025. House manager will ensure that maintenance checks regularly for any maintenance issue with the house. |