INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 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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704.11(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 (SRFSR) form, the facility failed to ensure that employee's #6 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on April 7, 2020 and was due to have the communicable disease trainings no later than April 7, 2021. The TB/STD training was completed on July 14, 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A for-cause clinical administration meeting was held by the Executive Director on November 9th, 2021, to review PA code 704.11 and retrain Clinical Supervisors on the requirements of the staff development program. The Executive Director and Director of Operations have been identified as the individuals responsible for ensuring overall compliance with this program through spread sheet tracking. The Director of Operations has also developed in-house curriculum for Basic HIV and TB/STD to make these trainings more available to newly hired staff. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #3's employee record.
Employee #3 was hired as a counselor on May 1, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee #3's employee record only documented 19.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A for-cause clinical administration meeting was held by the Executive Director on November 9th, 2021, to review PA code 704.11 and retrain Clinical Supervisors on the requirements of the staff development program. The Executive Director and Director of Operations have been identified as the individuals responsible for ensuring overall compliance with this program through spread sheet tracking. As of January 2021, Blueprints has adopted a new training platform called Relias to make trainings more readily available and accessible to staff to ensure hourly annual training requirements are met. |
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 client bathroom in the main hallway, bathroom outside of admissions, bathroom inside of admissions, men's and women's bathroom on first floor, and the staff bathroom on the second floor.
This is a repeat citation from January 15, 2021 annual licensing inspection.
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. The reason this was not completed last year was due to the cost prohibitive nature of the project hindering overall operations and the treatment services provided. 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 nature of the project cost and installation time, we expect to be in compliance with this regulation by January 1, 2022. |
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 tag.
The fire extinguishers in the lobby, two in the clinical area, one in the community room and three in the upstairs hallway were last serviced in 2020.
This is a repeat citation from January 15, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On this particular year our fire extinguishers were inspected, however the tags were not updated by the fire extinguished company. We have contacted the company to replace the incorrect tags and expect to have updated tags by the end of the month. Office Management 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 ensuring that the tags are correct post inspection from the extinguisher company. 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. 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. |
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 submitted documentation, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit on activities associated with the project's drug/alcohol abuse services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Officer (CEO) has secured the services of an independent CPA to conduct a fiscal audit relevant to Blueprints' drug and alcohol services for the calendar year 2020. This was expected to be completed by the time of the survey; however, we were held up by the outdated invoices from outside contractors. We expect to have the fiscal audit for 2020 completed by the end of November 2021. To avoid this in the future, the CEO will submit for an independent audit at the end of the first quarter of every year for the previous calendar year. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information in two out of seven records reviewed, as there were forms that were missing required information.
Client #1 was admitted on September 17, 2021 and was still active at the time of the inspection. There were consent to release forms, signed and dated on September 17, 2021 by the client to three external providers, a funding source, government agency and a family member, but the consent forms were signed by the client on September 17, 2021 and not signed by a witness until September 20, 2021
Client #7 was admitted on August 13, 2021 and was discharged on September 10, 2010. There were consent to release forms, signed and dated on August 13, 2021 by the client to three outside providers, a funding source, a government agency and a family member, but the consent forms were signed by the client on August 13, 2021 and not signed by a witness until August 15, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
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 Supervisors complete mechanical chart checks and content chart checks on a weekly basis. The Clinical Supervisors are responsible for checking all releases for completion and accuracy in areas including but not limited to dated signature of client and witness. A for-cause clinical administration meeting will be held by the Executive Director during the week of November 8th, 2021, to review PA code 709.28 and retrain on the proper completion of informed and voluntary consent from the client for the disclosure of information contained in the client record. |
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 client records, the facility failed to provide a complete client record, which is to include an individual treatment and rehabilitation plan including type and frequency of treatment and rehabilitation services in five out of seven records reviewed.
Client #1 was admitted on September 17, 2021 and was still active at the time of the inspection. A treatment plan dated September 20, 2021 and an updated dated October 22, 2021 did not include type and frequency of treatment and rehabilitation services.
Client #2 was admitted on September 24, 2021 and was still active at the time of the inspection. A treatment plan dated October 4, 2021 and an update dated October 21, 2021 did not include type and frequency of treatment and rehabilitation services.
Client #3 was admitted on September 27, 2021 and was still active at the time of the inspection. A treatment plan dated October 21, 2021 did not include type and frequency of treatment and rehabilitation services.
Client #6 was admitted on August 13, 2021 and was discharged on August 25, 2021. A treatment plan dated August 19, 2021 did not include type and frequency of treatment and rehabilitation services.
Client #7 was admitted on August 13, 2021 and was discharged on September 10, 2021. A treatment plan dated August 17, 2021 did not include type and frequency of treatment and rehabilitation services.
This is a repeat citation from January 15, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A for-cause clinical administration meeting was held by the Executive Director on November 9th, 2021, to review PA code 709.92 and retrain Clinical Supervisors on the requirements for treatment and rehabilitation plans. This meeting specifically reviewed the importance of including type and frequency of treatment and rehabilitation services on every individual treatment plan. Due to this being a repeat citation, it was determined that an adjustment would be made to where Blueprints includes this information on the treatment and rehabilitation plan in an effort to avoid future citations. Mechanical Chart Checks and Content Chart Checks continue to be a solution for ongoing compliance and ensuring that this deficiency does not recur in the future as well. The Clinical Supervisor will continue to complete chart checks on a weekly basis to ensure that type and frequency is being included on treatment and rehabilitation plans. |
709.82(a)(3) 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:
(3) Proposed type of support service.
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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 an individual treatment and rehabilitation plan including proposed type of support services in seven out of seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A for-cause clinical administration meeting was held by the Executive Director on November 9th, 2021, to review PA code 709.92 and develop a plan for the addition of "proposed type of support services" to the treatment and rehabilitation plan. It was decided during this meeting that this would be added as a new objective under the substance use disorder goal and the intervention would include support services that need to be developed or maintained by the client. Counseling staff will be informed of this addition during weekly clinical meeting on November 10th, 2021. 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 Supervisors complete mechanical chart checks and content chart checks on a weekly basis and are responsible for ensuring that this is a part of the treatment and rehabilitation plan moving forward. |