INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2019 to January 15, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Avenues Recovery Center of Bucks, LLC. 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to develop a mechanism to collect feedback on completed trainings in four personnel records reviewed.
Employee # 1 was hired as the project director on March 13, 2017.
Employee # 3 was hired as a counselor on November 14, 2016.
Employee # 4 was hired as a counselor on July 24, 2017.
Employee # 5 was hired as a counselor on May 23, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Regulatory Compliance will have the responsibility to develop a mechanism for collecting feedback on given training courses. The current training program used does collect these responses, however it is not shared with the facility. Moving forward, there will be a questionnaire completed by the staff after each training is completed about the relevancy, effectiveness, and areas of recommendations to allow the facility to continually improve the training program. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 3 of 16 client records reviewed. Additionally, the facility failed to document the dated witness signature in 9 of 16 client records reviewed.
Client # 1 was admitted to the partial hospitalization level of care on September 4, 2018 and was active at the time of the inspection. There were two consent forms to family members signed and dated by the client on September 5, 2018; however, both consent forms were missing the dated witness signature.
Client # 2 was admitted to the partial hospitalization level of care on October 25, 2018 and was active at the time of the inspection. There was a consent form to a family member signed and dated by the client on October 26, 2018; however, the consent form was missing the dated witness signature.
Client # 4 was admitted to the partial hospitalization level of care on May 31, 2018 and was discharged on September 21, 2018. There were two consent forms to family members signed and dated by the client on June 1, 2018; however, both consent forms were missing the dated witness signature.
Client # 5 was admitted to the partial hospitalization level of care on June 13, 2018 and was discharged on August 24, 2018. There was a consent form to an individual signed and dated by the client on June 13, 2018; however, the consent form was missing the dated witness signature. Additionally, there was documentation that the facility billed the funding source; however, there was no consent to release information form to the funding source documented prior to the disclosure of information.
Client # 6 was admitted to the partial hospitalization level of care on April 3, 2018 and was discharged on August 14, 2018. There was documentation of correspondence with a probation officer on July 24, 2018; however, there was no consent to release information form documented prior to disclosure of information.
Client # 7 was admitted to the partial hospitalization level of care on June 25, 2018 and was discharged on August 22, 2018. There were various consent forms to multiple treatment providers and individuals signed and dated by the client on June 25, 2018, June 27, 2018, July 3, 2018 and August 2, 2018; however, all of the consent forms were missing a dated witness signature.
Client # 8 was admitted to the outpatient level of care on September 21, 2018 and was active at the time of the inspection. There were two consent forms to family members signed and dated by the client on June 1, 2018; however, both consent forms were missing the dated witness signature. Additionally, there was documentation of a family counseling session held on October 25, 2018; however, there was no consent to release information form documented for one of the family members in attendance prior to the disclosure of information.
Client # 9 was admitted to the outpatient level of care on August 24, 2018 and was active at the time of the inspection. There was a consent to release form to an individual signed and dated by the client on June 13, 2018; however, the consent form was missing the dated witness signature. Additionally, there was documentation that the facility billed the funding source; however, there was no consent form to the funding source documented prior to the disclosure of information.
Client # 11 was admitted to the outpatient level of care on August 14, 2018 and was discharged on November 19, 2018. There were multiple consent forms to family members and an employer signed and dated by the client on June 25, 2018, July 13, 2018, August 23, 2018 and September 28, 2018; however, all of the consent forms were missing a dated witness signature.
Client # 12 was admitted to the outpatient level of care on August 22, 2018 and was discharged on December 21, 2018. There were two consent forms to family members signed and dated by the client on May 29, 2018 and July 13, 2018; however, both consent forms were missing a dated witness signature.
Client # 13 was admitted to the outpatient level of care on August 29, 2018 and was discharged on November 16, 2018. There were multiple consent forms to family members, the employer and the probation officer signed and dated by the client on June 4, 2018, June 6, 2018, July 11, 2018 and August 27, 2018; however, all of the consent forms were missing a dated witness signature.
Client # 14 was admitted to the outpatient level of care on August 28, 2018 and was discharged on September 28, 2018. There was a consent form to a family member signed and dated by the client on September 17, 2018; however, the consent form was missing a dated witness signature.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The informed and voluntary consent to release information form was updated in October 2018 to allow the staff to sign off on the form following the client's signature in the EMR.
Family sessions and phone calls to any person(s) will not be conducted without oversight from the therapist and Clinical Supervisor ensuring that there are appropriate releases in place prior to releasing any information on the patient.
Staff has been trained on HIPAA regarding this and all staff are aware to double check releases that have been signed by the patient prior to any disclosure of information. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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
The facility failed to properly document which type of services and the frequency the client was to receive on the client's individual treatment plan in three of seven client records reviewed.
Client # 4 was admitted on May 31, 2018 and was discharged on September 21, 2018. The comprehensive treatment plan was dated June 12, 2018.
Client # 6 was admitted on April 3, 2018 and was discharged on August 14, 2018. The comprehensive treatment plan was dated April 10, 2018.
Client # 7 was admitted on June 25, 2018 and was discharged on August 22, 2018. The individualized treatment plan was dated June 26, 2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The clinical staff has been retrained on entering all required information into the treatment plans and the importance of adding in the type and frequency as a framework to the client's treatment program.
The Clinical Supervisor who is responsible for auditing client records to ensure accuracy and timeliness is responsible for ensuring that the treatment plans are completed in their entirety prior to signing off on the treatment plans entered by the clinical staff. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to provide counseling to a client on a regular and scheduled basis, which is to include individual counseling at least twice a week, in three of seven records reviewed in the partial hospitalization activity.
Client # 4 was admitted on May 31, 2018 and was discharged on September 21, 2018. Documentation of two individual sessions per week was not completed for the weeks of August 29, 2018 to September 4, 2018 and September 12, 2018 to September 18, 2018.
Client # 6 was admitted on April 3, 2018 and was discharged on August 14, 2018. Documentation of two individual sessions per week was not completed for the weeks of July 22, 2018 to July 28, 2018 and July 29, 2018 to August 4, 2018.
Client # 7 was admitted on June 25, 2018 and was discharged on August 22, 2018. Documentation of two individual sessions per week was not completed for the week of July 15, 2018 to July 22, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical staff has been reminded about the requirement and importance of providing two individual sessions per week for client's in the partial hospitalization activity. Though the sessions were rescheduled due to conflicts in schedules, the need for the individual sessions are imperative to their treatment. The Clinical Supervisor will ensure that they were completed for the quality of care to the persons served during chart audits and during the scheduled weekly group supervision sessions with the clinical staff. |