INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2016, by staff from the Division of Drug and Alcohol 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The physical plant inspection was conducted on December 12, 2016. During the inspection of the facility's restrooms, the hot water temperature in the second floor restroom measured at 127 degrees F. The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Following the exit interview on 12/12/2016, the Director of Operations reached out to the Property Manager of the building where the project is housed, and requested access to the Utility System room where the water temperature can be adjusted.
The Property Manager responded on the following day - 12/13/2016 - and the Director of Operations adjusted the water temperature to below 120 degrees Fahrenheit.
By end-of-day 12/13/2016, the hot water temperature in the second floor restrooms measured at 118 degrees Fahrenheit at their highest temperature.
Blueprints for Addiction Recovery is now in full compliance with this Safety/Physical Plant standard, and has created provisions in the weekly Safety and Environment of Care Walkthrough forms (completed twice weekly by a Logistics Coordinator), including measurement of the water temperature, to ensure standards-compliance is maintained.
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709.28 (c) 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.
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Observations
Based on a review of client records on December 12, 2016, the facility failed to document informed and voluntary consents in client records, # 5, 6, 8 and 10. Client #5 was admitted to treatment on June 7, 2016 and still active at the time of the inspection. An informed and voluntary consent was completed for a funding source on June 7, 2016, but failed to include an expiration date and what specific information is being disclosed.Client #6 was readmitted on October 17, 2016 and still active at the time of the inspection. An informed and voluntary consent was completed for a funding source on September 6, 2016. The facility failed to include an expiration date and what specific information is being disclosed.Client #8 was admitted on November 18, 2016 and still active at the time of the inspection. An informed and voluntary consent was completed for a funding source on November 18, 2016. The facility failed to include an expiration date and what specific information is being disclosed.Client #10 was admitted to treatment on August 31, 2016 and discharged on November 18, 2016. An informed and voluntary consent was completed for a funding source on September 6, 2016. The facility failed to include an expiration date and what specific information is being disclosed.The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
On 12/15/2016, the Admissions and Evaluation policies of Blueprints for Addiction Recovery were officially amended to include completion of a "Consent to Disclose Information" form specifically for Insurance Companies/Funding Sources.
Completion of the "Consent to Disclose Information" form has taken the place of the "Assignment of Benefits/Authorization to Disclose" form that was determined insufficient by the Surveyor on 12/12/2016.
The Program Director has added completion of the "Consent to Disclose Information" form to the required Client Admission Checklist, as well as trained all Clinical and relevant Clerical/Administrative Staff on the completion of the above form.
The "Consent to Disclose Information" form includes the following essential criteria:
(1) Name of the person, agency or organization to whom disclosure is made
(2) Specific Information Disclosed
(3) Purpose of disclosure
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14 (a) and (b)
(5) Dated signature of witness
(6) Date, event or condition upon which the consent will expire
Blueprints for Addiction Recovery is now in full compliance with this standard, and has developed provisions (as stated above) to ensure ongoing compliance. |
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 on December 12, 2016, the facility failed to include the type and frequency of treatment and rehabilitation services in client records, #1, 2, 3, 8 and 9.Client # 1 was admitted on April 28, 2016 and discharged on May 25, 2016. The client's comprehensive treatment plan was completed on May 2, 2016.Client # 2 was admitted on May 6, 2016 and discharged on June 6, 2016. The client's comprehensive treatment plan was completed on May 12, 2016. Client # 3 was admitted on May 17, 2016 and discharged on June 15, 2016. The client's comprehensive treatment plan was completed on May 17, 2016. Client # 8 was admitted on November 18, 2016 and still active at the time of the inspection. The client's comprehensive treatment plan was completed on November 18, 2016. Client # 9 was admitted on November 30, 2016 and still active at the time of the inspection. The client's comprehensive treatment plan was completed on November 30, 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/16/2016, Blueprints for Addiction Recovery's "Treatment Planning" policies and procedures have been officially amended to include mandatory documentation of each client's type and frequency of rehabilitation services.
The Program Director has revised the policy and procedure as follows:
(1) On admission, during the completion of the "Initial Treatment Plan", the type and frequency of rehabilitation services is entered once under the "Intervention" tab, and again under the "Short-Term Goals" tab in the electronic health record.
The Program Director has alerted and trained the clinical team on the completion of the above, and has included monitoring of ongoing compliance as part of the Clinical Supervisors' "Clinical Chart Reviews" duties and procedures.
Blueprints for Addiction Recovery is now in full compliance with this standard, and has developed monitoring activities (as stated above) to ensure compliance is maintained.
AMENDED: The following corrections were made during the initial period of corrective action. However, Due to oversight, they were not documented in the original electronic Plan of Corrections:
The Program Director and the Clinical Director reviewed all active client charts and assigned corresponding counselors to update the Treatment Plan tabs to reflect type and frequency of rehabilitation services. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 on December 12, 2016, the facility failed to include the type and frequency of treatment and rehabilitation services in client records, #4, 5, 6, 7 and 10.Client # 4 was admitted on June 21, 2016 and discharged on August 11, 2016. The client's comprehensive treatment plan was completed on June 21, 2016. Client # 5 was admitted on June 7, 2016 and discharged on September 22, 2016. The client's comprehensive treatment plan was completed on June 7, 2016. Client # 6 was admitted on October 17, 2016 and still active at the time of the inspection. The client's comprehensive treatment plan was completed on October 17, 2016. Client # 7 was admitted on August 31, 2016 and still active at the time of the inspection. The client's comprehensive treatment plan was completed on August 31, 2016. Client # 10 was admitted on August 31, 2016 and discharged on October 27, 2016. The client's comprehensive treatment plan was completed on August 31, 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/16/2016, Blueprints for Addiction Recovery's "Treatment Planning" policies and procedures have been officially amended to include mandatory documentation of each client's type and frequency of rehabilitation services.
The Program Director has revised the policy and procedure as follows:
(1) On admission, during the completion of the "Initial Treatment Plan", the type and frequency of rehabilitation services is entered once under the "Intervention" tab, and again under the "Short-Term Goals" tab in the electronic health record.
The Program Director has alerted and trained the clinical team on the completion of the above, and has included monitoring of ongoing compliance as part of the Clinical Supervisors' "Clinical Chart Reviews" duties and procedures.
Blueprints for Addiction Recovery is now in full compliance with this standard, and has developed monitoring activities (as stated above) to ensure compliance is maintained.
AMENDED: The following corrections were made during the initial period of corrective action. However, Due to oversight, they were not documented in the original electronic Plan of Corrections:
The Program Director and the Clinical Director reviewed all active client charts and assigned corresponding counselors to update the Treatment Plan tabs to reflect type and frequency of rehabilitation services. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on December 12, 2016, the facility failed to document a treatment plan update at least every 60 days in client records, #4 and 7. Client # 4 stepped down from partial treatment to outpatient treatment on June 21, 2016 and discharged on August 11, 2016. The client's last treatment plan update was completed on May 24, 2016 while in the partial program. The facility failed to document a treatment plan update while the client was receiving treatment in outpatient. Client # 7 was admitted on August 31, 2016 and still active during the licensing inspection. The client's comprehensive treatment plan was completed on August 31, 2016 and the treatment plan should have been completed by October 31, 2016. The treatment plan update was completed on November 25, 2016. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 12/16/2016, Blueprints for Addiction Recovery's "Treatment Planning" policies and procedures have been officially amended to include emphasis on completion of "Treatment Plan Updates" within the time-frame regulated by the Department.
The Program Director has completed training for the Clinical Department, reemphasizing the importance of completing "Treatment Plan Updates" within the time-frame specified by the Department of Drug and Alcohol Programs, as well as assessing staff competency regarding the above.
Additionally, the Program Director has included specific provisions for monitoring standards-compliance to the Clinical Supervisors' "Clinical Chart Reviews" duties and procedures.
Blueprints for Addiction Recovery is now in full compliance with this standard, and has developed monitoring and compliance activities (as outlined above) to ensure ongoing compliance. |