INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13, 2022 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #8 was hired as a counselor on August 2, 2021 and was due to have the communicable disease trainings no later than August 2, 2022. TB/STD training was not completed until September 14, 2022.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 19, 2021 licensing inspection.
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Plan of Correction
The counselor in question completed the required TB/STD training approximately a month after the expected date.
DDAP approved HIV/AIDS and TB/STD in-house trainings are scheduled quarterly to ensure staffing compliance. This expectation was established between the Vice President and Chief Operating Officer, the Executive Administrator, the Director of Operations, and the Compliance Manager in an Administration Meeting on 8/23/2022.
The Human Resources Manager and Executive Administrator will continue to monitor supervisor's tracking of staff training records. The Director of Operations and the Compliance Manager will administer the quarterly HIV/AIDS and TB/STD trainings and support the Human Resources Manager and Executive Administrator in ensuring that all new staff are enrolled in the trainings within timeframes compliant with standards expectations.
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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
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2021.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the October 19, 2021 licensing inspection.
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Plan of Correction
The Vice President and Chief Business Development Officer will submit a request for exception to Standard 709.25: Fiscal Management on 10/28/2022 for the Fiscal Audit for tax year 2021.
The Vice President and Chief Business Development Officer, or compliance staff, will submit a request for exception to Standard 709.25: Fiscal Management in any tax year that Blueprints expects to file a tax extension.
The Fiscal Audit for tax year 2021 will be completed by an independent CPA as soon as all relevant accounting and tax-related documentation is furnished for their review within the timeframe specified in the request for exception. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information at seven days, sixty days, and 180 days, in one out of two applicable discharged records reviewed.
Client #7 was admitted on May 3, 2022 and was discharged on May 31, 2022. Per policy, a sixty-day follow-up call should have been completed no later than July 31, 2022. No follow-up was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The timeframe for 60 days was missed on Client #7's chart, and so cannot be completed. The 180-day follow-up call will be completed on November 22nd, 2022.
The Lancaster Site Director and Clinical Supervisor, previously the Clinical Supervisor of Mt Joy, updated the Mt Joy Census with improved conditional formatting to clarify for the Mt Joy Office Manager which follow-up calls are due on any given day and at any given timeframe. The Mt Joy Office Manager will complete follow-up calls and enter them into Blueprints' EMR daily. Calls expected to be made on weekends will be completed the Friday prior to the set date.
The Mt Joy Site Director and Clinical Supervisor will?in monthly supervision with the Mt Joy Office Manager?ensure compliance with the expectations for timeframes regarding follow-up information.
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