INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's January 1, 2021 through December 31, 2021 training year.
Employee #1 was hired as the Project Director on February 11, 2019. The personnel record documented 5 hours of training during the 2021 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrator is responsible for ensuring that the Facility Director maintains his ongoing training courses to meet 12 hours throughout each calendar year and following up on a regular basis to make sure trainings are completed throughout the training year. As of January, 2022, the Facility Director has received 20+ training hours for the 2022 training year. |
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 personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in three of four applicable personnel records reviewed.
Employee # 2 was hired as a counselor on November 14, 2016. The personnel record documented 21 hours of training received during the training year reviewed.
Employee # 3 was hired as a counselor on May 23, 2017. The personnel record documented 5 hours of training received during the training year reviewed.
Employee # 5 was hired as a counselor on August 18, 2018. The personnel record documented 0 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrator is responsible for ensuring that the clinical staff maintains their ongoing training courses to meet 25 hours throughout each calendar year and following up on a regular basis to make sure trainings are completed throughout the training year. As of January, 2022, these three counselors have received 25+ training hours for the 2022 training year. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in five of fourteen client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on April 28, 2021 and was discharged on October 24, 2021. There was a release of information form to a disability insurance provider, signed and dated by the witness on May 7, 2021, that allowed for the release of treatment plans, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations discharge planning, discharge summary and financial information, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 7 was admitted to the partial hospitalization activity on August 11, 2021 and was discharged on August 26, 2021. There was a release of information form to a government agency, signed and dated by the witness on May 12, 2021, that allowed for the release of treatment plans, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations discharge planning, discharge summary and financial information, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 10 was admitted to the outpatient activity on October 25, 2021 and was still active at the time of the inspection. There was a release of information form to a disability insurance provider, signed and dated by the witness on May 7, 2021, that allowed for the release of treatment plans, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations discharge planning, discharge summary and financial information, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 12 was admitted to the outpatient activity on July 6, 2021 and was discharged on August 10, 2021. There was a release of information form to a government agency, signed and dated by the witness on May 12, 2021, that allowed for the release of treatment plans, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations discharge planning, discharge summary and financial information, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 13 was admitted to the outpatient activity on November 11, 2021 and was discharged on December 20, 2021. There was a release of information form to a government agency, signed and dated by the witness on June 23, 2021, that allowed for the release of treatment plans, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, laboratory test results, employment information, legal status, family information, aftercare recommendations discharge planning, discharge summary and financial information, all of which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the February 18, 2020 and March 24, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Quality Assurance Liaison will be responsible for ensuring that the staff only uses the approved 4 Pa Code 255.5 Release of Confidential Information form to limit correspondence disability insurance provider(s), and government agencies. The Quality Assurance Liaison will be responsible for oversight that information to be sent/communicated on the patient's behalf to ensure protection of client confidentiality is met within the scope of 4 Pa Code 255.5. The electronic medical record utilized at the facility was previously updated to have a standard release for Insurance, Disability/FMLA, and Governmental Agencies which restricts information being disclosed pursuant to 4 PA Code 255.5. The staff has been retrained on utilizing the standard ROIs that meet 4 PA Code 255.5 and Client #10 resigned ROI within the scope of the details above. All other current patient records have been reviewed and no other charts were out of compliance with this regulation. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in two of fourteen client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on April 28, 2021 and was discharged on October 24, 2021. The release of information forms to an outside individual and a FMLA Coordinator were signed and dated by the client on April 28, 2021, but neither form documented the purpose of the disclosure.
Client # 10 was admitted to the outpatient activity on October 25, 2021 and was still active at the time of the inspection. The release of information forms to an outside individual and a FMLA Coordinator were signed and dated by the client on April 28, 2021, but neither form documented the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Quality Assurance Liaison is responsible for making sure that all patients have complete and accurate records, which includes ensuring that the purpose of disclosure on release of information forms is documented. Client #10 resigned the release of information which documents the purpose of disclosure and all other active patient charts were reviewed and found to be in compliance. |
709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on release of information forms in one of fourteen client records reviewed.
Client # 14 was admitted to the outpatient activity on October 21, 2021 and was discharged on December 27, 2021. The record contained a release of information form to the primary care physician that was signed and dated by the client on July 19, 2021; however, the form failed to document the dated signature of the witness.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Quality Assurance Liaison is responsible for ensuring that patient records are complete and accurate, including witness signatures on release of information are documented. The Quality Assurance Liaison reviewed all active patient charts and all were found to be in compliance. |