INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 2025 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of twenty employee records reviewed.
Employee #6 was hired as a Counselor on March 17, 2025 and was still in the position as of the date of the inspection. The plan is dated April 30, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A Training Plan for the staff member in question was created prior to the licensing process; it was not completed within the expected timeframe.
Since the error in April of 2025, the Human Resources department at Blueprints has made two improvements that will prevent reoccurrence of this issue:
1) All staff that are onboarded or are change hires must have HR Tickets created for them in order for the changes to occur and for the staff to be onboarded into their new position. The ticketing system utilized specifically identifies the completion of the Training Plan as an essential?and timebound?component of the onboarding process. The progress made in onboarding and change hire tickets is reviewed daily by the HR Associate and twice per week by the Executive Administrator to ensure the timeliness of vital and timebound HR activities.
2) Blueprints has transitioned to a new electronic Human Resources Management platform that has coding functionality where required items can be automatically assigned, reviewed, completed, and audited by the various staff involved in employee onboarding and also in HR Management. The HR Associate is automatically notified when Training Plans are due for completion, monitors to ensure none surpass the upper limit of the timing expectation, and coordinates with supervisors to ensure the timely completion of training plans. The Executive Administrator reviews all pending tasks in the HRM platform weekly to ensure no vital and timebound elements are left incomplete.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employee #3 was hired as a Counselor on August 19, 2024. His training was due no later than August 19, 2025; however, his HIV/AIDS training was not completed as of the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The staff member in question completed the missing HIV Training prior to the end of the licensing process.
As a result of this error, the Human Resources department at Blueprints has instituted a new monitoring process where Blueprints' Training Certificate Upload Database must be audited once per week by the Human Resources Associate, Program Administrator, and/or Compliance Officer to identify any trainings that remain incomplete and to ensure the completion of those trainings within the required timeframe.
All trainings completed by Blueprints staff must be submitted via the Training Certificate Upload Form, which populates the Training Certificate Upload Database in real time. The Training Certificate Upload Database is coded to have timing expectations for all staff members based on their experience, their job position, and their training year. Therefore, a weekly audit of the timeliness of the database will ensure that mandatory trainings cannot remain incomplete without discovery by the HR team.
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