INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on September 24-25, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site investigation, 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 investigation:
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Plan of Correction
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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
Based on the review of a client record during a complaint investigation conducted on September 24-25, 2026, the facility failed to include the type and frequency of treatment and rehabilitation services on an individual treatment and rehabilitation plan.
Client # 1 was admitted on July 20, 2026, and discharged on August 26, 2026. The individual treatment and rehabilitation plan dated July 23, 2026, did not include the type and frequency of services.
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Plan of Correction
Upon notification of the survey findings, the Compliance Officer and the Site Director reviewed the cited treatment plan together and verified that the omission involved the documentation of service type and frequency within the individual treatment and rehabilitation plan. The treatment process itself was completed as intended; however, the required service frequency language was not documented in the treatment plan.
The Site Director conducted retraining with all Program Therapists on 10/1/2026 regarding treatment planning requirements under Chapter 709 regulations. The retraining emphasized the requirement that all treatment plans include the type and frequency of treatment and rehabilitation services, including individual therapy, group therapy, family therapy, and any other clinically indicated interventions.
To promote consistency and reduce the likelihood of future omissions, standard treatment plan language has been incorporated into treatment planning practices. Treatment plans will include clearly defined service frequencies, including but not limited to:
- Individual Therapy: 1x weekly
- Group Therapy: Daily
- Family Therapy: As clinically indicated and/or weekly through scheduled family sessions
The Site Director or Clinical Operations Manager will conduct monthly audits of a sample of active treatment plans to verify compliance with treatment planning requirements. Findings will be reviewed during supervision and staff meetings. Staff demonstrating recurring documentation deficiencies will receive additional retraining and, when necessary, individualized corrective action plans. This auditing and monitoring process will continue in perpetuity as a component of the organization's quality improvement and compliance oversight activities.
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709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on the review of a client record during a complaint investigation conducted on September 24-25, 2026, the facility failed to provide correct case consultation notes.
Client # 1 was admitted on July 20, 2026, and discharged on August 26, 2026. The Case Consult Notes dated August 3, 2026, and August 19, 2026, each had " None " typed on the line provided for the " multidisciplinary treatment team members completing the case consult. "
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Plan of Correction
Upon notification of the survey findings, the Compliance Officer and the Site Director reviewed the cited client record together and verified that the required interdisciplinary case consultation had been completed; however, the consultation note did not accurately document the multidisciplinary treatment team member with whom the consultation occurred. The notation of "None" in the consultation documentation was entered in error and did not accurately reflect the consultative process that occurred.
The Site Director conducted retraining with all Program Therapists on 10/1/2026 regarding the requirements for completing and documenting case consultations. The retraining included a review of documentation standards, the purpose of interdisciplinary consultation, and expectations for consultation with nursing, psychiatry, case management, peer support staff, and other treatment team members as clinically appropriate.
The Site Director and Clinical Operations Managers will increase oversight of clinical documentation through weekly reviews of a sample of client charts to ensure that required case consultations are completed accurately, thoroughly, and in accordance with regulatory requirements. Particular attention will be given to ensuring that consultation notes clearly identify the multidisciplinary treatment team member involved in the consultation and document the content and outcome of the communication.
When deficiencies are identified, immediate feedback and corrective coaching will be provided to the responsible staff member. Documentation compliance will also be reviewed during routine clinical supervision sessions, with recurring deficiencies addressed through additional retraining and, when necessary, individualized corrective action plans.
To ensure sustained compliance, monthly chart audits will be conducted by Clinical Leadership. Audit findings and trends will be reviewed during staff meetings, and corrective actions will be implemented as needed. This monitoring process will continue in perpetuity as part of the organization's ongoing compliance and performance improvement program.
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