Observations
Based on a physical plant inspection, the facility failed to provide ventilation by exhaust fan or window in each bathroom. The bathroom window did not open and there was not an exhaust fan.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The bathroom in question was immediately addressed on the date of survey; the Maintenance Team removed the restriction to the bathroom window that prevented its ability to open. This was verified by the Director of Operations.
The Environment of Care Walkthrough Form utilized biweekly at all Blueprints Recovery Residences was updated to include verification of a functional exhaust fan or window for bathrooms. Residential Leadership and other Residential staff responsible for completing the process were retrained by the Compliance Officer and the Director of Operations on 8/15/2025.
The Compliance Officer has established an additional monthly auditing process, which began on 8/15/2025, to verify the completion of this additional form field and, in instances of negative responses, will immediately delegate correction to the Maintenance Team and the Director of Operations. This monthly auditing process will continue in perpetuity as a function of the Safety Committee.
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