INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17-18, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection P1S96701 Blueprints For Addiction Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection, and a plan of correction is required.
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Plan of Correction
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§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on two four discharged resident records reviewed, the facility failed to provide written notification to the residents stating the decision to end residency.Resident #5 was admitted on January 22, 2026, and was discharged January 23, 2026. There was no documentation of an end to residency in the resident record.Resident # 6 was admitted on April 14, 2026, and discharged April 26, 2026. There was no documentation of an end to residency in the resident record.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As the residents referenced in this observation have been discharged and the termination letters were already out of date, there is no corrective action to be taken regarding their records.
Program staff responsible for completing termination discharge documentation?including termination letter communication and documentation?were retrained in timing and completion expectations on 7/1/2026 in staff meetings.
Supervisory staff responsible for the delegation of and monitoring of the timely completion of termination letters were reoriented to the timing expectations and the expectation that they request and verify the completion of this letter within the proper timeframe in a staff retraining on 6/30/2026.
The Compliance Manager for a period of 90 days?or longer if there are continued issues?will check all discharging client charts two times per week to catch any patterns of errors with discharge documentation. Data will be reported weekly to the Compliance Officer.
Ongoing, the Compliance Manager will communicate with Program Leadership weekly to confirm that discharges for each week had discharge documentation completed within the correct timeframe. The Compliance Manager was trained in these expectations by the Compliance Officer on 7/2/2026. |
§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
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Observations
Based on two of four applicable discharged resident records reviewed, the facility failed to provide notification within 12 hours to the emergency contact stating the resident ' s decision to end residency or not returning to the drug and alcohol recovery house as expected.Resident #5 was admitted on January 22, 2026, and was discharged January 23, 2026. The emergency contact was not notified of the residents ending residency within 12 hours. The emergency contact was notified on January 30, 2026.Resident #7 was admitted on March 30, 2026, and was discharged April 3, 2026. The emergency contact was not notified of the residents ending residency within 12 hours. The emergency contact was notified on April 21, 2026.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
As the residents referenced in this observation have been discharged and the emergency contact communication was already out of date, there is no corrective action to be taken regarding their records.
Program staff responsible for completing emergency contacts and documentation were retrained in timing and completion expectations on 7/1/2026 in staff meetings.
Supervisory staff responsible for the delegation of and monitoring of the timely completion of emergency contacts and documentation were reoriented to the timing expectations and the expectation that they request and verify the completion of this activity within the proper timeframe in a staff retraining on 6/30/2026.
The Compliance Manager for a period of 90 days?or longer if there are continued issues?will check all discharging client charts two times per week to catch any patterns of errors with discharge documentation. Data will be reported weekly to the Compliance Officer.
Ongoing, the Compliance Manager will communicate with Program Leadership weekly to confirm that discharges for each week had discharge documentation completed within the correct timeframe. The Compliance Manager was trained in these expectations by the Compliance Officer on 7/2/2026. |