INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from January 13, 2021 to January 15, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of eleven personnel records, the facility failed to ensure that one counselor assistant was given a written semiannual performance evaluation based upon measurable performance standards.
Employee # 7 was hired on July 29, 2019 as a counselor assistant. Employee #7 did not receive a semiannual performance evaluation in the last year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Blueprints for Addiction Recovery, as a project, will begin completing written semiannual performance evaluations for all staff employed in a Counselor Assistant position. The Clinical Supervisors of each clinical counseling facility will be responsible for ensuring that these are completed. A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 704.9 and retrain Clinical Supervisors on the requirements of supervision of a counselor assistant. The Executive Director is ultimately responsible for ensuring that the Clinical Supervisors complete these semiannual evaluations with the Counselor Assistants in a timely fashion. This will be tracked utilizing the Company's Human Resources Management excel spreadsheet and documentation will be securely held in the Company's cloud-based HRM Solution ? Zenefits. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of eleven personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.
Employee #7 was hired on July 29, 2019 as a counselor assistant. Employee # 7 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #7 did not receive close supervision from November 2019- July 2020. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision only reported formal case reviews occurred and direct observation did not.
Employee #8 was hired on February 10, 2020 as a counselor assistant. Employee #8 has an associate degree and may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment. Employee #8 did not receive close supervision from February 2020 - November 2020. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision only reported formal case reviews occurred and direct observation did not.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Blueprints for Addiction Recovery, as a project, will begin completing and documenting close supervision defined by regulation as, "formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week". The Clinical Supervisors of each clinical counseling facility will be responsible for ensuring that supervision is correctly engaged in and documented appropriately. A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 704.9 and retrain Clinical Supervisors on the requirements of supervision of a Counselor Assistant. At that time, the Executive Director will also review DDAP Licensing Alert 4-02 which clearly defines staffing regulations and requirements for direct observation and close supervision of Counselor Assistants. The Executive Director is ultimately responsible for ensuring that the Clinical Supervisors are trained adequately and are supervising Counselor Assistants according to regulation. The Executive Director will complete monthly audits on Counselor Assistant supervision documentation to ensure compliance with this regulation. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window.
The women ' s bathroom in the assessment area did not have an operable fan or window.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will contact High Associates, the owner of the building, and submit a maintenance request to have the fan fixed in the women's bathroom in the clinical wing of the building. The fan was broken at the time of the survey and is expected to be fixed in a timely fashion. Biweekly Environment of Care walkthroughs have been identified as a way of ensuring ongoing compliance with this standard. Moving forward, these walkthroughs will assist in finding inoperable fans or ventilation and the above will occur anytime a fan is deemed inoperable. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of nine fire drill records, the facility failed to maintain a written fire drill record including the exit route used, problems encountered and whether the fire alarm or smoke detector was operative.
The facility 's fire drill record did not include a section to identify the exit route used.
The fire drill record for February 11, 2020 and August 28, 2020 did not note if any problems were encountered.
The fire drill record on August 28, 2020 did not include whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager will be retrained on how to complete and record fire drills including but not limited to documenting the exit route used, problems encountered during the drill, and whether the fire alarm or smoke detector was operative. If needed, the fire drill record will be updated to define these areas of regulation more clearly. The Executive Director is ultimately responsible for ensuring these corrective actions occur and this deficiency does not recur in the future by reviewing monthly fire drill logs when they are submitted for filing. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of nine fire drill records, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The fire drill records for August 28, 2020 did not include whether the fire alarm or smoke detector was set off.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manager will be retrained on how to complete and record fire drills including the importance of setting off fire alarm or smoke detectors during each fire drill. If needed, the fire drill record will be updated to define these areas of regulation including a section more clearly for documenting that fire alarms or smoke detectors were set off during each drill. The Executive Director is ultimately responsible for ensuring these corrective actions occur and this deficiency does not recur in the future by reviewing monthly fire drill logs when they are submitted for filing. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of seven client records, the facility failed to document a client orientation to the project that included a familiarization with the fee schedule in all seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Lancaster Clinical Orientation Handbook will be updated to include free schedule for clinical services provided. Patients will continue to sign off that the Clinical Orientation Handbook was reviewed with them at the time of intake/evaluation. The Executive Director will be responsible for updating the Orientation Handbook to include the fee schedule and providing the updated handbook to Counseling staff. 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 Supervisor will continue to complete chart checks on a weekly basis to ensure that orientation sessions are occurring and that the patient is signing off for receipt of the handbook. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to develop individual treatment and rehabilitation plans with six clients that included written documentation of type and frequency of treatment and rehabilitation services.
Client #2 was admitted on September 27, 2019 and discharged on November 4, 2019. An individual treatment and rehabilitation plan dated October 17, 2019 did not document service type.
Client # 3 was admitted on July 15, 2020 and was current at the time of inspection. Individual treatment and rehabilitation plans dated July 15, 2020, September 11, 2020 and December 26, 2020 did not document type and frequency of treatment and rehabilitation services.
Client #4 was admitted on October 6, 2020 and was current at the time of inspection. Individual treatment and rehabilitation plans dated October 6, 2020, December 7, 2020, and December 31, 2020 did not document type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on December 7, 2020 and was current at the time of inspection. An individual treatment and rehabilitation plan dated December 7, 2020 did not document type and frequency of treatment and rehabilitation services.
Client #6 was admitted on January 7, 2021 and was current at the time of inspection. An individual treatment and rehabilitation plan dated January 7, 2021 did not document type and frequency of treatment and rehabilitation services.
Client #7 was admitted on August 21, 2020 and was current at the time of inspection. Individual treatment and rehabilitation plans dated August 21, 2020, October 14, 2020, November 4, 2020, and December 22, 2020 did not document type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A for-cause clinical administration meeting will be held by the Executive Director during the week of March 15th, 2021 to review PA code 709.92 and retrain Clinical Supervisors on the requirements for treatment and rehabilitation plans. This meeting will specifically review the importance of including type and frequency of treatment and rehabilitation services on every individual treatment plan. 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 Supervisor will continue to complete chart checks on a weekly basis to ensure that type and frequency is being include on treatment and rehabilitation plans. |