INITIAL COMMENTS
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This report is a result of an on-site recovery house complaint investigation conducted on May 4, 2026 through May 12, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Blueprints for Addiction Recovery was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717, which pertains to the recovery house.
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Plan of Correction
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§ 717.24 LICENSURE Medication control and self-administration
§ 717.24. Medication control and self-administration. The licensee shall develop and implement written policies and procedures on the use of prescription and over-the-counter medications by residents, which must include:
(1) Self-administration of medication for residents who take medication.
(2) Safe storage of medication by the drug and alcohol recovery house and residents and procedures to address loss, theft, abandonment or misuse of medications. The policy must provide that controlled substances stored at the drug and alcohol recovery house will be kept in a locked container.
(3) Safe disposal of unused, expired or abandoned medication, in accordance with State and Federal regulations.
(4) Emergency procedures if an adverse medication reaction or overdose occurs on premises. The licensee shall have and make available overdose reversal medication on the premises of the drug and alcohol recovery house at all times.
(5) Prohibition on sharing prescription medication.
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Observations
Following the request to review personnel records, internal incident reports and staff interviews it was determined staff failed to follow the written policies and procedures to ensure:1) Self- administration of medication for residents who take medication. 2) Safe storage of medication which includes controlled substances be kept in a locked container.
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Plan of Correction
During an investigative review of internal protocols as a result of this incident, it was discovered that not all clients who maintained personal lockboxes for the purpose of their medications being stored behind two locks (one the lockbox and the other the safe on site) were directed to make a unique code known only to them. Upon the discovery of this non-adherence to protocol all staff in the Residential Services department who provide lockboxes for clients to use were retrained in the expectation that clients be instructed to create a unique code, not provide that code to anyone else?especially staff or clients?and that they immediately request support in adjusting their code if another individual were to learn their unique code.
This training was issued by Residential Management and occurred between 4/28/2026 and 5/4/2026 to capture all staff in the department. Medication Management policies were reviewed and revised to add additional clarity to guide future staff training and to prevent reoccurrence of this concern.
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§ 717.31(c)(2) LICENSURE Unusual incidents - 3-day Filing
§ 717.31. Unusual incidents.
(c) The licensee shall file a written unusual incident report with the Department within three business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Following the request to review personnel records, internal incident reports and staff interviews it was determined staff failed to file a written unusual incident report with the Department within three business days following an unusual incident involving serious injury due to medication error.
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Plan of Correction
An unusual incident report regarding the events related to this site review was submitted on 5/8/2026. The incident occurred on 4/27/2026.
On 5/8/2026 the Licensing Specialist Supervisor informed the Compliance Officer of the error and clarified that the expectation for unusual incident reporting is for a report to be submitted under the classification "Serious Injury" to follow the definition that follows: "an adverse event that results in significant harm or impairment to a patient. This includes situations where the error leads to death, substantial disruption of normal life functions, or requires medical intervention or treatment to prevent permanent impairment or damage, assessment for allergic or other negative reaction. A visit to the hospital as a result of a medication error is viewed as a substantial disruption to normal life functions. Unplanned medical treatment and urgent, or emergency room visit results in anxiety, stress, unbudgeted expenses, loss of time, missed work, and many other impacts on one's personal life and wellbeing."
Going forward we will continue to comply with the PA Code and its internal policy by filing a written unusual incident within three days for any occurrence involving an event at any drug and alcohol recovery house that meets the above definition.
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