INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12, 2022 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #2 was hired as a counselor on October 16, 2018 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2021 through December 31, 2021. Employee #2's record only documented 23.5 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The counselor in question missed the timeframe to complete their 25 hours of annual training and so is unable to meet the specific timeframe requirement.
The HR Manager and Executive Administrator will monitor supervisor's tracking of staff training records monthly to ensure compliance with expectations specific to the Standard 704.11.
Clinical Supervisors will establish an annual training plan with counselors that at minimum meets the requirements of their position. Clinical supervisors will manage training certificates, ensure compliance with training plans, and submit verification to the HR Manager and Executive Administrator as trainings are completed.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2021.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the November 3, 2021 licensing inspection.
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Plan of Correction
The Vice President and Chief Business Development Officer will submit a request for exception to Standard 709.25: Fiscal Management on 10/28/2022 for the Fiscal Audit for tax year 2021.
The Vice President and Chief Business Development Officer, or compliance staff, will submit a request for exception to Standard 709.25: Fiscal Management in any tax year that Blueprints expects to file a tax extension.
The Fiscal Audit for tax year 2021 will be completed by an independent CPA as soon as all relevant accounting and tax-related documentation is furnished for their review within the timeframe specified in the request for exception.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
Client #1was admitted on March 4, 2022 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The counselor for the client in question completed a consent to release information form for the client's funding source with the client during the client's first session following the time of inspection on 11/10/2022.
The Site Director and Clinical Supervisor educated the clinical team during a regular clinical staff meeting on 11/1/2022 on the process of reviewing records for active releases of information before any contact is made.
The Site Director and Clinical Supervisor implemented a new procedure on 11/14/2022 where all clients whose funding source is currently county funding will, at the time of evaluation, both sign a consent for their reporting county and for the Medical Assistance provider associated with their county, as the existing standard operating procedure is to assist and guide clients on county funding in enrolling with their Medical Assistance provider.
This, combined with our other existing auditing procedures, will ensure that all our clients have active release of information forms for all funding sources. Our Intake Manager and Intake Specialists were trained on this procedure in a staff meeting on 11/15/2022. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary within seven days of discharge per policy in one out of three discharged records reviewed.
Client #7 was admitted on January 6, 2022 and was discharged on May 26, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The discharge summary in question was completed, though it was completed outside of the stipulated timeframe. No further steps can be taken as the issue of non-compliance was dictated by time.
The Site Director and Clinical Supervisor educated the clinical team during a regular clinical staff meeting on 11/1/2022 on the process and dictated timeframe requirements for complete client records.
The Site Director and Clinical Supervisor augmented our internal census to include a new tab specifically dedicated to clients who have discharged but whose discharge summary has not yet been completed. Clients will only be moved by the Site Director and Clinical Supervisor to this specific tab when their discharge process has begun, and can only be removed from it by the Site Director and Clinical Supervisor when the counselor responsible for the client's discharge summary has communicated that the discharge summary has been completed.
The Site Director and Clinical Supervisor will verify the completeness of the client's record before shifting the client to the Discharge Census. The Site Director and Clinical Supervisor will monitor this new tab daily in order to ensure that discharge summaries are completed in the seven day timeframe. This new procedure was communicated to staff during the Clinical Staff Meeting on 11/15/2022.
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