INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19, 2021 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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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 submitted documentation, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit on activities associated with the project ' s drug/alcohol abuse services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Officer (CEO) has secured the services of an independent CPA to conduct a fiscal audit relevant to Blueprints' drug and alcohol services for the calendar year 2020. The audit was expected to be completed by the time of the survey; however, we were held up by the outdated invoices from outside contractors. We expect to have the fiscal audit for 2020 completed by the end of November 2021. To avoid this in the future, the CEO will submit for an independent audit at the end of the first quarter of every year for the previous calendar year. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of seven client records reviewed.
Client #7 was admitted on March 25, 2020 and discharged on May 4, 2021. There was documentation of correspondence with the funding source dated March 31, 2021 through May 4, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Mechanical Chart Checks and Content Chart Checks have been identified as a solution for ongoing compliance and ensuring that this deficiency does not recur in the future. The Clinical Supervisors complete mechanical chart checks and content chart checks on a weekly basis and are responsible for checking releases for completion and accuracy in all areas. A for-cause clinical administration meeting will be held by the Executive Director during the week of November 8th, 2021, to review PA code 709.28 and retrain on the proper completion of informed and voluntary consent from the client for the disclosure of information contained in the client record. |
709.93(a)(11) 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:
(11) Follow-up information.
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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 follow-up information in two out of four discharged records reviewed. The policy and procedure manual states follow-up after seven days of discharge.
Client #4 was admitted on November 17, 2020 and was discharged on January 15, 2021.
Client #7 was admitted on March 25, 2020 and was discharged on May 4, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility policy will remain the same (follow up will be conducted at 7, 60, and 180 days following a client's discharge from treatment). The office manager at each site location is responsible for the completion and documentation of follow ups. The clinical site director/clinical supervisor is responsible for training office manager staff, follow up, and oversight to ensure this deficiency does not occur again. |