INITIAL COMMENTS
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This report is a result of an on-site renewal licensure inspection conducted on January 14-15, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, BTI46701 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. 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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§ 717.27 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 a review of discharged residents records, the facility failed 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.
Resident # 6 was admitted on May 14, 2025, and discharged May 16, 2025. The emergency contact was to be made within twelve hours of May 16, 2025; however, was not notified until May 19, 2025.
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Plan of Correction
The Discharge Checklist utilized by Program Counselors and Program Therapists to verify and garner approval from a supervisor to finalize the discharge process has been updated to include specific information regarding contacting a client's Emergency Contact and when it must be completed by the clinician as opposed to by supervisory leadership or residential staff as the cause of the missing emergency contacts was due to a lack of clarity in the responsible party depending on the time of the client's discharge.
The Compliance Officer, in collaboration with the Program Director, conducted retraining sessions for all Clinical Leadership, Program Therapists, and Residential Staff during a staff meeting on 1/29/2026. The retraining emphasized the responsibility of clinical team members vs. supervisory leadership vs. residential staff, the update to the Discharge Checklist, and reiterated timeframe expectations of the completion of Emergency Contacts. Particular attention was given to the need to complete the Emergency Contact in all cases and within 12 hours of discharge.
Further, to strengthen interdepartmental collaboration and to allow for more ease of compliance accountability, we have revised our EMR to have a singular place for staff in both our Residential and Clinical departments to document Emergency Contact communications. The note template available also requires staff to attest that they have reviewed the active Releases on file and attest that the release for the individual to be contacted is accurate, matches the name of the individual to be contacted, and has not been revoked, rather than accessing contact information on the "Information" tab of KIPU which does not automatically update to reflect changes related to revocation. If they do not indicate that they have reviewed the "Releases" tab, the remainder of the note will not populate for their completion.
Staff were trained in this new form and form location on 1/29/2026. The Compliance Officer or an appropriate designee will review this new note monthly and cross reference it with discharge data to ensure that all Emergency Contacts are appropriately made within the expected 12 hours and will issue discipline and/or retraining as necessary to non-compliant staff.
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§ 717.29(e)(3) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120°F.
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Observations
Based on a physical plant inspection, the facility failed to keep the water temperature from exceeding 120 degrees Fahrenheit. The water temperature in the bathroom was read at 138 degrees Fahrenheit.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The water heater for the residence in question was immediately addressed on the date of survey; the Maintenance Team adjusted the maximum water temperature to be below 120 degrees Fahrenheit. 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 temperature below 120 degrees Fahrenheit. Residential Leadership and other Residential staff responsible for completing the process were retrained by the Compliance Officer and the Director of Operations on 1/27/2026.
The Compliance Officer has established an additional monthly auditing process, which began on 1/27/2026, 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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