INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, the facility did not provide documentation that any full-time employees were trained in first aid, and failed to demonstrate sufficient coverage of staff trained in first aid during the project's hours of operation for the time period of April 28, 2016 through February 7, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction is to at least have 2 full time staff members certified in First Aid and CPR on the premises during all hours of operation. We are in the process of having current staff obtain this certification. As of March 13, 2017 our full time Facility Director has already obtained CPR and First Aid Training. Our Director of Operations will be responsible for ensuring that Avenues is compliant with 704.11, CPR Certification going forward. |
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 a 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 client record #'s 2 and 3 in the Partial Hospitalization activity, and for client record #'s 5, 6, 8, and 10 in the Outpatient activity. Additionally, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 7 in the Outpatient activity.
Client #2 was admitted to the Partial Hospitalization activity on 1/30/17 and was an active client at the time of inspection. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #3 was admitted to the Partial Hospitalization activity on 2/6/17 and was an active client at the time of inspection. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #5 was admitted to the Outpatient activity on 5/26/16 and was discharged on 7/29/16. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #6 was admitted to the Outpatient activity on 8/29/16 and was discharged on 12/12/16. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #7 was admitted to the Outpatient activity on 8/22/16 and was discharged on 11/18/16. The record contained two consent to release information forms to a probation officers, signed and dated on 9/8/16, which allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the discharge summary, treatment plan and updates, and UDS screens. The record also contained a consent to release information form to a government official, signed and dated on 9/8/16, which allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the discharge summary and treatment plan and updates.
Client #8 was admitted to the Outpatient activity on 10/31/16 and was an active client at the time of inspection. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #10 was admitted to the Outpatient activity on 11/22/16 and was an active client at the time of inspection. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction going forward is to have every client sign a release for funding sources and government officials that is limited to the following 5 concepts; being in or out of treatment, the nature of the project, prognosis/diagnosis, short statement of relapse and frequency of relapse. The Facility Director will be responsible for creating new consents that are limited to the 5 concepts as well and revoke any established consents that were outside of those concepts. This will be accomplished in the next 30 days and it is the Facility Directors responsibility for making sure it is accomplished. Moving forward the Facility Director will be responsible for ensuring that staff utilize the correct releases. |
709.81(b)(2)(ii) LICENSURE Intake and admission
709.81. 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:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility to provide documentation that clients were informed of the project's hours of operation as part of the orientation process in client record #'s 1, 2, and 3.
Client #1 was admitted to the Partial Hospitalization activity on 1/26/17 and was an active client at the time of inspection.
Client #2 was admitted to the Partial Hospitalization activity on 1/30/17 and was an active client at the time of inspection.
Client #3 was admitted to the Partial Hospitalization activity on 2/6/17 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our plan of correction is that the hours of operation have been added to the Program Orientation form and all current clients have been asked to sign a new Program Orientation form, so this has already been rectified. Going forward the Facility Director will be responsible for training all staff to have all new intakes sign this form as part of the Admissions Packet. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to include in the intake and admission process, a drug and alcohol history that included details of route of administration or a personal history that included sexual information in client record #'s 2 and 3.
Client #2 was admitted to the Partial Hospitalization activity on 1/30/17 and was an active client at the time of inspection.
Client #3 was admitted to the Partial Hospitalization activity on 2/6/17 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction is that the Facility Director will be responsible for training all staff who are completing intake assessments to complete the Biopsychosocial and Medical Assessment in its entirety and making sure that the route of administration is filled out and that personal history about sexual information is recorded. As of March 15, 2017 this was completed for all current clients and the Facility Director is responsible for ensuring that this information is obtained for the last client. |
709.91(b)(2)(ii) 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:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility to provide documentation that clients were informed of the project's hours of operation as part of the orientation process in client record #'s 4, 5, 6, 7, 8, 9, and 10.
Client #4 was admitted to the Outpatient activity on 11/4/16 and was discharged on 2/3/17.
Client #5 was admitted to the Outpatient activity on 5/26/16 and was discharged on 7/29/16.
Client #6 was admitted to the Outpatient activity on 8/29/16 and was discharged on 12/12/16.
Client #7 was admitted to the Outpatient activity on 8/22/16 and was discharged on 11/18/16.
Client #8 was admitted to the Outpatient activity on 10/31/16 and was an active client at the time of inspection.
Client #9 was admitted to the Outpatient activity on 11/10/16 and was an active client at the time of inspection.
Client #10 was admitted to the Outpatient activity on 11/22/16 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our plan of correction is that the hours of operation were added to the Program Orientation form and all current clients were asked to sign this new form so this problem has already been rectified. Moving forward this form will be reviewed with clients during the intake process. The Facility Director will be responsible moving forward to make sure that all staff makes the clients aware of the hours of operation on the Program Orientation form. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to include in the intake and admission process, a personal history that included sexual information in client record #'s 4, 5, 6, 8, 9, and 10.
Client #4 was admitted to the Outpatient activity on 11/4/16 and was discharged on 2/3/17.
Client #5 was admitted to the Outpatient activity on 5/26/16 and was discharged on 7/29/16.
Client #6 was admitted to the Outpatient activity on 8/29/16 and was discharged on 12/12/16.
Client #8 was admitted to the Outpatient activity on 10/31/16 and was an active client at the time of inspection.
Client #9 was admitted to the Outpatient activity on 11/10/16 and was an active client at the time of inspection.
Client #10 was admitted to the Outpatient activity on 11/22/16 and was an active client at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction is to make sure that the Emotional/Behavioral section of the Biopsychosocial is completed in its entirety during the intake assessment process, which includes sexual information of the clients. The Facility Director will be the person responsible for ensuring that all counselors who are completing the intake assessments are trained to complete the entire Biopyschosocial. As of March 15, 2017 all of the existing clients except of one has had their Biopyschosocial updated to included the missing sexual information and the Facility Director is responsible for making sure that the information is also obtained for this last client. |