INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2024 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from September 2023 through August 2024, the facility failed to document the time of the drill for the August 2024 fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources/Safety Director, prior to this licensing survey, updated the Fire Drill procedure to digitize its documentation and to ensure that required fields could not be skipped during the completion of a drill and its documentation. The responsible party for Fire Drills at Mount Joy did not adopt this process and continued to complete Fire Drills using the outdated paper system.
Retraining for Office Management, directed by the Human Resources/Safety Director, occurred on 9/30/2024 and covered the digitized form, which does not allow for submission before all fields are completed, as well as the relevant PA Code Reference so responsible staff would understand the full expectation of the process. The digitized form was also updated to include warnings against repeat exit routes and timing of drills.
The Human Resources/Safety Director on 10/1/2024 also increased the frequency of his review of submitted Fire Drills from Quarterly to bimonthly to ensure that no more than two drills could ever utilize the same exit routes, be conducted at the same time of the month, and/or be conducted at the same time of day.
The Compliance Officer also instituted an additional personal quarterly monitoring review on 10/1/2024 to ensure that noncompliance not caught by the Human Resources/Safety Director would not continue.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from September 2023 through August 2024, the facility failed to prepare alternative exit routes to be used during fire drills, as all drills utilized the same front exit routes.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Human Resources/Safety Director, prior to this licensing survey, updated the Fire Drill procedure to digitize its documentation and to ensure that required fields could not be skipped during the completion of a drill and its documentation. The responsible party for Fire Drills at Mount Joy did not adopt this process and continued to complete Fire Drills using the outdated paper system.
Retraining for Office Management, directed by the Human Resources/Safety Director, occurred on 9/30/2024 and covered the digitized form, which does not allow for submission before all fields are completed, as well as the relevant PA Code Reference so responsible staff would understand the full expectation of the process. The digitized form was also updated to include warnings against repeat exit routes and timing of drills.
The Human Resources/Safety Director on 10/1/2024 also increased the frequency of his review of submitted Fire Drills from Quarterly to bimonthly to ensure that no more than two drills could ever utilize the same exit routes, be conducted at the same time of the month, and/or be conducted at the same time of day.
The Compliance Officer also instituted an additional personal quarterly monitoring review on 10/1/2024 to ensure that noncompliance not caught by the Human Resources/Safety Director would not continue.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs from September 2023 through August 2024 the facility failed to conduct a fire drill on different days of the week, at different times of the day and night and on different staffing shifts as twelve out of twelve fire drills were conduct at 10:45 am.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Human Resources/Safety Director, prior to this licensing survey, updated the Fire Drill procedure to digitize its documentation and to ensure that required fields could not be skipped during the completion of a drill and its documentation. The responsible party for Fire Drills at Mount Joy did not adopt this process and continued to complete Fire Drills using the outdated paper system.
Retraining for Office Management, directed by the Human Resources/Safety Director, occurred on 9/30/2024 and covered the digitized form, which does not allow for submission before all fields are completed, as well as the relevant PA Code Reference so responsible staff would understand the full expectation of the process. The digitized form was also updated to include warnings against repeat exit routes and timing of drills.
The Human Resources/Safety Director on 10/1/2024 also increased the frequency of his review of submitted Fire Drills from Quarterly to bimonthly to ensure that no more than two drills could ever utilize the same exit routes, be conducted at the same time of the month, and/or be conducted at the same time of day.
The Compliance Officer also instituted an additional personal quarterly monitoring review on 10/1/2024 to ensure that noncompliance not caught by the Human Resources/Safety Director would not continue.
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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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven client records reviewed.
Client #1 was admitted on April 2, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 24, 2024 and the next update was due no later than June 24, 2024; however, there was no update documented in the record until August 13, 2024.
Client #2 was admitted on July 11, 2024, and was still active at the time of the inspection. A treatment plan update was completed on July 15, 2023 and the next update was due no later than August 15, 2024; however, there was no update documented in the record until August 23, 2024.
Client #3 was admitted on July 23, 2024, and was still active at the time of the inspection. A treatment plan update was completed on July 25, 2024, and the next update was due no later than August 25, 2024; however, there was no update documented in the record at the time of the inspection.
Client #5 was admitted on February 7, 2024 and was discharged on June 2, 2024. A treatment plan update was completed on March 27, 2024 and the next update was due no later than April 27, 2024; however, there was no update documented in the record until May 21, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Compliance Officer updated the "Treatment Plan Update" Policy to ensure clarity that Treatment Plan Updates are expected to reoccur rather than to simply occur one time during a client's treatment stay. It was also updated to specify that (1) Treatment Plan Updates may occur prior to the upper limit of the expected update, and (2) Case Consults are now considered "Case Consult and Treatment Plan Updates" and the EMR has been updated to reflect this expectation.
In the EMR, the "Case Consult Note" has been revised to the "Case Consult and Treatment Plan Update Note" with space for documenting the progress made and updates made regarding treatment plan goals, as well as attestation that, as needed, Treatment Plan Goals are also updated.
Secondly, in the Census utilized for each Level of Care, a column was added that automatically calculates and highlights when the difference between Today's date and the client's date of admission falls between 25-29 days, 55-59 days, 85-89 days, etc for PHP and 55-59 days, 115-119 days, 175-179 days, etc for OP levels of care. Program Therapists will be able to see clearly when Treatment Plan Updates are due and Clinical Leadership will daily filter the census and send reminders to clinicians until the update is completed.
Notification of these changes was made on 10/7/2024 by the Compliance Officer and retraining of Program Therapists took place on 10/7/2024, led by Mount Joy Clinical Leadership. The above policy updates regarding frequency, the nature of treatment plan updates, and the relationship with Case Consultation was covered.
The Compliance Officer updated pre-existing Case Consult auditing procedures that compare length of time in treatment for each client to the required time window for a Case Consult by Level of Care to ensure that any delayed Case Consults would never bring required Treatment Plan Updates outside of the window of expectation.
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