INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11, 2020 and February 12, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.9(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
During a licensing inspection conducted on February 11, 2020 through February 12, 2020, the project failed to ensure that counselor assistants with a high school diploma or GED equivalent counseled clients under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and under the close supervision for the next 9-months. Employee # 8 was hired on June 13, 2018 as a counselor assistant and was a current employee at the time of the licensing inspection. There was no documentation indicating that this counselor assistant received close supervision; one hour of weekly case review and one hour of weekly direct observation for the months of January, February, March, April and May.Employee # 9 was hired on July 1, 2019 as a counselor assistant and was a current employee at the time of the licensing inspection. There was no documentation indicating that this counselor assistant received close supervision; one hour of weekly case review and one hour of weekly direct observation for the months of November, December and January.Employee # 10 was hired on August 2, 2019 as a counselor assistant and was a current employee at the time of the licensing inspection. There was no documentation indicating that this counselor assistant received close supervision; one hour of weekly case review and one hour of weekly direct observation for the months of December and January.Employee # 11 was hired on February 18, 2019 as a counselor assistant and was a current employee at the time of the licensing inspection. There was no documentation indicating that this counselor assistant received close supervision; one hour of weekly case review and one hour of weekly direct observation for the months of June, July, August, September, October, November, December and January.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Identified staff missing required supervision, under Blueprints job descriptions, are currently identified as clinical specialists and do not carry a caseload. Moving forward staff identified as clinical specialists will be trained and provided supervision congruent with DDAP regulations for counselor assistant. Clinical supervisor will provide supervision and document supervision for all staff identified as clinical specialists. Program Director will review supervision of clinical specialists with Clinical Supervisor to ensure quality compliance with this measure.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
During a licensing inspection conducted on February 11, 2020 through February 12, 2020, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Chief Executive Officer will secure the services of an independent CPA to conduct a fiscal audit relevant to Blueprints' drug and alcohol services. Due to our fiscal year being the calendar year, we will utilize the services of the independent CPA to conduct audits for fiscal years 2018 and 2019. Both of these audits will be complete and available for review by June 1, 2020. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
During a licensing inspection conducted on February 11, 2020 through February 12, 2020, the project failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record that documented the purpose of disclosure.Client #7 was admitted on October 29, 2019 and discharged on December 10, 2019. This client's record contained an informed and voluntary consent form for a law enforcement agency that failed to document the purpose of disclosure. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Program Director will conduct an in-service with all staff. This will include a review of completion of consent for disclosure documents. This will be inclusive of documenting the purpose of disclosure. All staff completing consent for disclosure documents with clients will review and document the purpose of the consent. Admission and Ongoing charts will be reviewed by Compliance Officer and/or Program Director weekly to ensure compliance with this correction. This will be added to the existing weekly chart reviews.
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
During a licensing inspection conducted on February 11, 2020 through February 12, 2020, the project failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record that documented a dated signature of the client.Client #7 was admitted on October 29, 2019 and discharged on December 10, 2019. This client's record contained an informed and voluntary consent form for a law enforcement agency that failed to document the date the client signed the consent. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Program Director will conduct an in-service with all staff. This will include a review of completion of consent for disclosure documents. This will be inclusive of reviewing appropriate signatures and dating of all consents.
All staff completing consent for disclosure documents with clients will have clients sign and date all consents. Admission and Ongoing charts will be reviewed by Compliance Officer and/or Program Director weekly to ensure compliance with this correction. This will be added to the existing weekly chart reviews.
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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
During a licensing inspection conducted on February 11, 2020 through February 12, 2020, the project failed to develop individual treatment and rehabilitation plans that included type and frequency of treatment and rehabilitation services. Client #1 was admitted on December 19, 2019 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan was completed on December 20, 2019 and an updated treatment and rehabilitation plan was completed January 21, 2020. Both treatment and rehabilitation plans failed to document the type and the frequency of treatment and rehabilitation services to be provided.Client #2 was admitted on December 21, 2019 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan was completed on December 23, 2019 and an updated treatment and rehabilitation plan was completed January 22, 2020. Both treatment and rehabilitation plans failed to document the type and the frequency of treatment and rehabilitation services to be provided.Client #3 was admitted on December 28, 2019 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan was completed on December 30, 2019 and an updated treatment and rehabilitation plan was completed January 30, 2020. Both treatment and rehabilitation plans failed to document the type and the frequency of treatment and rehabilitation services to be provided.Client #4 was admitted on January 6, 2020 and was a current client at the time of the inspection. A comprehensive individual treatment and rehabilitation plan was completed on January 7, 2020 and an updated treatment and rehabilitation plan was completed February 10, 2020. Both treatment and rehabilitation plans failed to document the type and the frequency of treatment and rehabilitation services to be provided.Client #5 was admitted on October 17, 2019 and was discharged on November 18, 2019. A comprehensive individual treatment and rehabilitation plan was completed on October 22, 2019. This comprehensive individual treatment and rehabilitation plan failed to document the type and the frequency of treatment and rehabilitation services to be provided.Client #6 was admitted on November 14, 2019 and was discharged on December 9, 2019. A comprehensive individual treatment and rehabilitation plan was completed on November 15, 2019. This comprehensive individual treatment and rehabilitation plan failed to document the type and the frequency of treatment and rehabilitation services to be provided.Client #7 was admitted on October 29, 2019 and was discharged on December 10, 2019. A comprehensive individual treatment and rehabilitation plan was completed on October 30, 2019 and an updated treatment and rehabilitation plan was completed November 25, 2019. Both treatment and rehabilitation plans failed to document the type and the frequency of treatment and rehabilitation services to be provided.Client #8 was admitted on December 9, 2019 and was discharged on January 4, 2020. A comprehensive individual treatment and rehabilitation plan was completed on December 11, 2019. This comprehensive individual treatment and rehabilitation plan failed to document the type and the frequency of treatment and rehabilitation services to be provided.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Program Director will conduct an in-service with all staff. This will address development and documentation of comprehensive treatment plans. This training will include, but not be limited to, the need for type and frequency of treatment and rehabilitation services, to be provided, be reflected in the treatment plan. All staff responsible for developing comprehensive treatment plans with clients will attend, or document review of materials, this training. Staff will include type and frequency of treatment into plans with each client. Program Director and/or Clinical Supervisor will randomly select a recently developed treatment plan and review with staff in supervision monthly.
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