INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 28, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on April 28, 2026, the facility failed to keep the grounds in good repair at all times.The women's bathroom was observed to have paint peeled off parts of the drywall in two bathroom stalls.
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Plan of Correction
On the date of survey, 4/28/2026, the Executive Administrator communicated to the Director of Operations of the identified physical plant concerns. Tickets were created within the Maintenance ticketing system and corrections were completed by 5/4/2026. The women's bathroom is in good repair.
Further, the Director of Operations participated in a retraining of the Office Manager Supervisor and the Homestead Office Manager to ensure that such physical plant issues would be identified and properly rectified as a result of the biweekly Environment of Care inspections that occur at the Homestead site, conducted by the Homestead Office Manager. Office Management staff was reminded that they are required to submit Maintenance tickets whenever physical plant concerns are identified during EOC inspections or ad hoc.
The Director of Operations and/or the Maintenance Supervisor will conduct quarterly site walkthroughs to catch any inconsistencies in the execution of this protocol, beginning 6/1/2026.
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on April 28, 2026, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.Inside the women ' s bathroom, the third stall was observed to have a mold-like substance in the corner and along the cove base molding.
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Plan of Correction
On the date of survey, 4/28/2026, the Executive Administrator communicated to the Director of Operations of the identified physical plant concerns. Tickets were created within the Maintenance ticketing system and corrections were completed by 5/4/2026. The women's bathroom is in good repair.
Further, the Director of Operations participated in a retraining of the Office Manager Supervisor and the Homestead Office Manager to ensure that such physical plant issues would be identified and properly rectified as a result of the biweekly Environment of Care inspections that occur at the Homestead site, conducted by the Homestead Office Manager. Office Management staff was reminded that they are required to submit Maintenance tickets whenever physical plant concerns are identified during EOC inspections or ad hoc.
The Director of Operations and/or the Maintenance Supervisor will conduct quarterly site walkthroughs to catch any inconsistencies in the execution of this protocol, beginning 6/1/2026.
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705.27 (3) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
During a complaint investigation conducted on April 28, 2026, the facility failed to limit smoking to designated smoking areas. The facility has a sign on the front door stating there is to be no smoking or vaping within 25 feet of the door. A person was observed vaping while standing beside a vehicle parked in front of the front door. This person was within 25 feet of the door.
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Plan of Correction
On the date of survey, 4/28/2026, the Executive Administrator communicated to the Chapter Two Clinical Operations Manager and the Chapter Two Residential Manager the general safety and emergency concern related to adherence to the expectations surrounding designated smoking areas. On 4/29/2026 the Chapter Two Clinical Operations Manager and the Chapter Two Residential Manager created clearer markings in the parking lot to identify the smoking/vaping area and retrained their staff in the expectations surrounding the use of the designated smoking/vaping area and their responsibility to uphold those expectations with clients and visitors. The client community was also addressed by the Chapter Two Clinical Operations Manager in both the morning and the evening.
The Chapter Two Clinical Operations Manager added a review of this policy to the agenda for the weekly Chapter Two Staff Meeting, ensuring that retraining in the policy and expectations of staff will reoccur no less frequently than quarterly.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the client handbook, Client Rights, and administrative paperwork, the facility failed to allow a client the right to inspect their own record.Client # 2 was admitted on 2/6/26 and discharged on 2/17/26. This client requested a copy of their individual treatment plan. Per administrative documentation, the client was not given a copy of their individual treatment plan.
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Plan of Correction
As Client #2 is no longer in our care, reconciliation of the request for the treatment plan could not be completed, although past clients may also request copies of their records at any time.
As indicated in the administrative documentation referenced in the notice of this plan of correction, the Client Orientation Handbook was revised prior to this site survey and by 4/10/2026 to state "You may request access to your treatment records as stated in the 'Client Rights' section of this handbook. Note that if you request paper copies of your records, you are responsible for the maintenance of your own confidential information; as such we will often encourage you to review your records with a Blueprints staff member, rather than printing paper copies."
Further, Homestead clinical staff were reoriented to the expectations surrounding client rights?particularly those related to the provision to a client of access to their own records and the protocols surrounding such requests?on 5/12/2026 by the Clinical Operations Manager.
The Clinical Operations Manager added a review of this policy to the agenda for the bi-weekly Chapter One Staff Meeting, ensuring that retraining in the policy and expectations of staff will reoccur no less frequently than quarterly.
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