INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 6, 2023 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:
|
Plan of Correction
|
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window in the community room women's bathroom.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/8/2023, the Director of Operations informed Blueprints' Maintenance Team of this deficiency and requested priority installation of an exhaust fan in the indicated bathroom.
This installation was completed on 10/9/2023.
On 9/22/2023, a section was added to Blueprints' internal Safety & Environment of Care Walkthroughs specifically regarding the presence and functionality of bathroom exhaust fans. These walkthroughs are conducted bi-weekly by Office Management or directorial staff, with any unusual results being communicated to the Director of Operations for resolution.
|
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of ten records reviewed.
Client #1 was admitted on February 23, 2023 and was still active at the time of the inspection. A treatment plan update was completed on March 24, 2023 and an update was due no later than April 23, 2023; however, it was not completed until May 9, 2023.
Client #4 was admitted on July 18, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 18, 2023 and an update was due no later than August 18, 2023; however, it was not completed until August 22, 2023.
Client #5 was admitted on July 19, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 21, 2023 and the next update was due no later than August 21, 2023; however, it was not completed until August 23, 2023.
Client #6 was admitted on November 14, 2022 and was discharged on June 20, 2023. A comprehensive treatment plan was completed on November 16, 2022 and an update was due no later than December 16, 2022; however, it was not completed until December 28, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The treatment plan updates in question were completed, though they were completed outside of the stipulated timeframe. No further steps can be taken as the issue of non-compliance was dictated by time, though a case management note explaining the error has been added to each client's treatment record.
The Site Director and Clinical Supervisor educated the clinical team during a regular clinical staff meeting on 10/3/2023 on the process and dictated timeframe requirements for complete client records, as well as to update staff on the following improvements.
The Site Director and Clinical Supervisor augmented Blueprints' internal census to include conditional formatting to highlight client records approaching a needed treatment plan update. This functionality streamlines pre-existing internal auditing procedures for directors, supervisors, and compliance staff to ensure that any clients approaching the timeframe of a Treatment Plan Update have TPUs completed within the appropriate time. Counselors will also be able to utilize this visibility function to manage their own day-to-day tasks and, with frequent reminders from supervisory staff, will be set up for success in this regard.
The Site Director and Clinical Supervisor and Clinical Supervisors perform regular mechanical chart reviews of all ongoing client records for the presence and timeliness of required chart elements to ensure any hiccoughs in this new process are caught and summarily addressed. This new procedure was communicated to staff during the Clinical Staff Meeting on 10/3/2023.
|
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/8/2023, the Chapters Program Director updated the display to conspicuously include Blueprints' main telephone number, for use in emergency situations, and the hours of operation for that site.
During a staff meeting between the Chapters Program Director, Executive Administrator, and Human Resources Director on 9/22/2023, it was established that the Chapters Program Director will assume responsibility for monitoring, updating, and posting the hours of project operation and emergency telephone number on a monthly basis. This ensures that the information is always current and readily available to the general public.
To further prevent future instances of non-compliance, this item to the Safety & Environment of Care Walkthroughs on 9/22/2023 by the Human Resources Director, which are completed biweekly. During these walkthroughs, our staff assess the safety, cleanliness, and security of the site, including the display of the required information.
|
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/8/2023, the Chapters Program Director updated the display to conspicuously include Blueprints' main telephone number, for use in emergency situations, and the hours of operation for that site.
During a staff meeting between the Chapters Program Director, Executive Administrator, and Human Resources Director on 9/22/2023, it was established that the Chapters Program Director will assume responsibility for monitoring, updating, and posting the hours of project operation and emergency telephone number on a monthly basis. This ensures that the information is always current and readily available to the general public.
To further prevent future instances of non-compliance, this item to the Safety & Environment of Care Walkthroughs on 9/22/2023 by the Human Resources Director, which are completed biweekly. During these walkthroughs, our staff assess the safety, cleanliness, and security of the site, including the display of the required information. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/8/2023, the Chapters Program Director updated the display to conspicuously include Blueprints' main telephone number, for use in emergency situations, and the hours of operation for that site.
During a staff meeting between the Chapters Program Director, Executive Administrator, and Human Resources Director on 9/22/2023, it was established that the Chapters Program Director will assume responsibility for monitoring, updating, and posting the hours of project operation and emergency telephone number on a monthly basis. This ensures that the information is always current and readily available to the general public.
To further prevent future instances of non-compliance, this item to the Safety & Environment of Care Walkthroughs on 9/22/2023 by the Human Resources Director, which are completed biweekly. During these walkthroughs, our staff assess the safety, cleanliness, and security of the site, including the display of the required information. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 9/8/2023, the Chapters Program Director updated the display to conspicuously include Blueprints' main telephone number, for use in emergency situations, and the hours of operation for that site.
During a staff meeting between the Chapters Program Director, Executive Administrator, and Human Resources Director on 9/22/2023, it was established that the Chapters Program Director will assume responsibility for monitoring, updating, and posting the hours of project operation and emergency telephone number on a monthly basis. This ensures that the information is always current and readily available to the general public.
To further prevent future instances of non-compliance, this item to the Safety & Environment of Care Walkthroughs on 9/22/2023 by the Human Resources Director, which are completed biweekly. During these walkthroughs, our staff assess the safety, cleanliness, and security of the site, including the display of the required information. |