INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Blueprints For Addiction Recovery, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that one clinical supervisor who had not functioned for 2 years as supervisor in the provision of clinical services shall complete a core curriculum in clinical supervision. Employee # 2 was hired as a clinical supervisor on June 1, 2020 and was still active in that position at the time of the inspection. Employee #2 had not functioned for 2 years as a supervisor in the provision of clinical services and failed to complete a core curriculum in clinical supervision. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 has registered for the DDAP-Approved Clinical Supervision Training and is expected to attend the week of March 15th, 2021. Going forward, Blueprints will ensure that a Clinical Supervisor who has not functioned for 2 years as supervisor in the provision of clinical services completes a core curriculum in clinical supervision prior to entering the role, if possible, or within 6 months of being hired into that position. The Executive Director is ultimately responsible for ensuring current and ongoing compliance by maintaining accurate Human Resources files in the company HRM system ? Zenefits. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that three counselors qualified for the position based on their education and experience.Employee # 5 was hired on February 24, 2020 as a counselor. Employee #5 had a qualifying master ' s degree but did not have a practicum in a health or human service agency or three months of close supervision.Employee #6 was hired on March 30, 2020 as a counselor. Employee #6 had a qualifying bachelor ' s degree but did not have one year of clinical experience in a health or human service agency.Employee #7 was hired on March 30, 2020 as a counselor. Employee #7 had a qualifying bachelor ' s degree but did not have one year of clinical experience in a health or human service agency.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The employees referenced in this observation were hired by a staff member who was unfamiliar with the experience and education that qualifies an individual for the position of Counselor. At this current time, the referenced employees either no longer work for Blueprints (by their own choice) or qualify accurate for the position that they are in. A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 704.7 and retrain Clinical Supervisors on the requirements for qualification of the position of Counselor. It is ultimately the responsibility of the Executive Director to ensure current and ongoing compliance with this regulation and all clinical hiring will need to be approved through the ED moving forward. If the ED is unsure whether an individual qualifies for the position of Counselor, he/she will reach out to DDAP and seek further clarification/approval to avoid any instances of non-compliance in the future. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that three counselor assistants were given a written semiannual performance evaluation based upon measurable performance standards.Employee # 9 was hired on April 14, 2017 as a counselor assistant. Employee #9 did not receive a semiannual performance evaluation in the last year.Employee #10 was hired on July 1, 2019 as a counselor assistant. Employee #10 did not receive a semiannual performance evaluation in the last year.Employee #11 was hired on February 18, 2019 as a counselor assistant. Employee #11 did not receive a semiannual performance evaluation in the last year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Blueprints for Addiction Recovery, as a project, will begin completing written semiannual performance evaluations for all staff employed in a Counselor Assistant position. The Clinical Supervisors of each clinical counseling facility will be responsible for ensuring that these are completed. A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 704.9 and retrain Clinical Supervisors on the requirements of supervision of a counselor assistant. The Executive Director is ultimately responsible for ensuring that the Clinical Supervisors complete these semiannual evaluations with the Counselor Assistants in a timely fashion. This will be tracked utilizing the Company's Human Resources Management excel spreadsheet and documentation will be securely held in the Company's cloud-based HRM Solution ? Zenefits. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of fourteen personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee #10 was hired on July 1, 2019 as a counselor assistant. Employee #10 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #10 did not receive close supervision from February 2020 to July 2020. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision on February 3, 2020, February 21, 2020, February 24, 2020, March 2, 2020, March 17, 2020, April 6, 2020, April 13, 2020, April 23, 2020, April 30, 2020, May 7, 2020, May 14,2020, May 21, 2020, June 11, 2020, June 18, 2020, and July 2, 2020 neither direct observation or case review occurred. On May 28, 2020 direct observation occurred but a case review did not. On June 4, 2020 and June 25, 2020, a case review occurred but direct observation did not.Employee #12 was hired on April 7, 2020 as a counselor assistant. Employee #12 has a bachelor ' s degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Employee #12 did not receive close supervision from April 2020 - September 2020. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision on April 14, 2020, April 21, 2020; May 5, 2020; May 19, 2020; June 12, 2020, June 18, 2020, June 26, 2020, June 30, 2020, July 9, 2020, July 16, 2020, July 22, 2020, August 6, 2020, August 12, 2020, August 17, 2020, August 29, 2020, September 12, 2020, September 19, 2020, September 26, 2020 neither direct observation or case review occurred. On April 28, 2020, May 12, 2020, and September 5, 2020 direct observation occurred but a case review did not. On September 5, 2020 a case review occurred but direct observation did not.Employee #12 did not have any documented supervision the weeks of May 24, 2020 -May 30, 2020 and May 31, 2020 - June 6, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Blueprints for Addiction Recovery, as a project, will begin completing and documenting close supervision defined by regulation as, "formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week". The Clinical Supervisors of each clinical counseling facility will be responsible for ensuring that supervision is correctly engaged in and documented appropriately. A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 704.9 and retrain Clinical Supervisors on the requirements of supervision of a Counselor Assistant. At that time, the Executive Director will also review DDAP Licensing Alert 4-02 which clearly defines staffing regulations and requirements for direct observation and close supervision of Counselor Assistants. The Executive Director is ultimately responsible for ensuring that the Clinical Supervisors are trained adequately and are supervising Counselor Assistants according to regulation. The Executive Director will complete monthly audits on Counselor Assistant supervision documentation to ensure compliance with this regulation. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the exterior of the building and the building grounds free of hazards. Outside of the second floor back exit there were pallets blocking the door. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager staff will be retrained in the importance of ensuring the exterior of the building and the building grounds are free of hazards. Biweekly Environment of Care walkthroughs have been identified as a way of ensuring compliance with this regulation and ensuring that this deficiency does not recur. Senior Leadership will meet with the Director of Operations to inform of the plan for correcting this deficiency. The Director of Operations and Office Manager are ultimately responsible for ensuring these corrective actions occur and this deficiency does not recur in the future. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window in the search room bathroom, client bathroom in main hallway, bathroom outside of admissions, bathroom inside admissions door, first floor women's bathroom, first floor men's bathroom, and the staff bathroom on the second floor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will work with Blueprints' Maintenance staff to begin installing exhaust fans in all bathrooms at this facility that do not have a way of ventilating by exhaust fan or window. Post installation, biweekly Environment of Care walkthroughs have been identified as a way of ensuring ongoing compliance with this standard. These walkthroughs will assist in finding inoperable fans and routine maintenance will occur to ensure that the exhaust fans are in working order. Due to the amount of fans that will need to be ordered and installed, the corrective action date has been set for the end of April, 2021. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility 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 nonresidential facility are unobstructed. The exit in the dining area would not open and the second-floor emergency exit had pallets outside blocking the door from opening. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager staff will be retrained in the importance of ensuring that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed. Biweekly Environment of Care walkthroughs have been identified as a way of ensuring compliance with this regulation and ensuring that this deficiency does not recur. Senior Leadership will meet with the Director of Operations to inform of the plan for correcting this deficiency. The Director of Operations and Office Manager are ultimately responsible for ensuring these corrective actions occur and this deficiency does not recur in the future. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag.The fire extinguisher in the basement was last serviced in 2019These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Office Manager staff will be retrained in the importance of ensuring that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company including but not limited to the fire extinguisher housed in the basement of the facility. Biweekly Environment of Care walkthroughs have been identified as a way of ensuring compliance with this regulation and ensuring that this deficiency does not recur. Senior Leadership will meet with the Director of Operations to inform of the plan for correcting this deficiency. The Director of Operations and Office Manager are ultimately responsible for ensuring these corrective actions occur and this deficiency does not recur in the future. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of nine fire drill records, the facility failed to maintain a written fire drill record including the exit route used and problems encountered.The fire drill record did not include a section to identify the exit route used and the fire drills on January 7, 2020, February 17, 2020, and March 10, 2020 did not indicate if any problems were encountered. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager will be retrained on how to complete and record fire drills including but not limited to documenting the exit route used and problems encountered during the drill. If needed, the fire drill record will be updated to define these areas of regulation more clearly. The Executive Director is ultimately responsible for ensuring these corrective actions occur and this deficiency does not recur in the future by reviewing monthly fire drill logs when they are submitted for filing. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of nine fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.The fire drill record for April 10, 2020 and September 11, 2020 did not include which exit route was used during the drill. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager will be retrained on how to complete and record fire drills including but not limited to preparing alternate exit routes to be used during fire drills. If needed, the fire drill record will be updated to define these areas of regulation more clearly. The Executive Director is ultimately responsible for ensuring these corrective actions occur and this deficiency does not recur in the future by reviewing monthly fire drill logs when they are submitted for filing. |
709.81(b)(2)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of seven client records, the facility failed to document the client orientation to the project which includes a familiarization with the fee schedule in all seven records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chapter One Clinical Orientation Handbook will be updated to include free schedule for clinical services provided. Patients will continue to sign off that the Clinical Orientation Handbook was reviewed with them at the time of intake/evaluation. The Executive Director will be responsible for updating the Orientation Handbook to include the fee schedule and providing the updated handbook to Counseling staff. Mechanical Chart Checks and Content Chart Checks have been identified as a solution for ongoing compliance and ensuring that this deficiency does not recur in the future. The Clinical Supervisor will continue to complete chart checks on a weekly basis to ensure that orientation sessions are occurring and that the patient is signing off for receipt of the handbook. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to develop an individual treatment and rehabilitation plan with three clients that included written documentation of the type and frequency of treatment and rehabilitation services.Client #3 was admitted on December 24, 2020 and was still current. The treatment and rehabilitation plan dated December 30, 2020 did not include the type and frequency of treatment and rehabilitation services.Client #4 was admitted on November 23, 2020 and was still current. The treatment and rehabilitation plans dated November 23, 2020 and December 23, 2020 did not include the type and frequency of treatment and rehabilitation services.Client #7 was admitted on December 9, 2019 and discharged on December 26, 2019. The treatment and rehabilitation plans dated December 10, 2019 and December 24, 2019 did not include the type of treatment and rehabilitation services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 709.92 and retrain Clinical Supervisors on the requirements for treatment and rehabilitation plans. This meeting will specifically review the importance of including type and frequency of treatment and rehabilitation services on every individual treatment plan. Mechanical Chart Checks and Content Chart Checks have been identified as a solution for ongoing compliance and ensuring that this deficiency does not recur in the future. The Clinical Supervisor will continue to complete chart checks on a weekly basis to ensure that type and frequency is being include on treatment and rehabilitation plans. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven client records, the facility failed to provide individual counseling to three clients, at least twice weekly.Client #3 was admitted on December 24, 2020 and was still current. The client only had one individual session the week of December 27, 2020- January 2, 2021. Client #4 was admitted on November 23, 2020 and was still current. The client only had one individual session the week of November 29, 2020 - December 5, 2020. There was no documentation of any individual sessions the week of December 6, 2020 - December 12, 2020.Client #6 was admitted on December 8, 2020 and was still current. The client only had one individual session the week of December 13, 2020 - December 19, 2020. There was no documentation of any individual sessions the week of January 3, 2021- January 9, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 709.82 and retrain Clinical Supervisors at the facility on the requirements for treatment and rehabilitation services. This meeting will specifically review the importance of each individual patient engaging in individual counseling at least twice weekly. Mechanical Chart Checks and Content Chart Checks have been identified as a solution for ongoing compliance and ensuring that this deficiency does not recur in the future. The Clinical Supervisor will continue to complete chart checks on a weekly basis to ensure that individual counseling is occurring at least twice weekly for every patient in Partial Hospitalization. |