INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 12, 2018 through February 13, 2018 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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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 the review of the fire drill logs for February 2017 through December 2017, the facility failed to document whether the fire alarm or smoke detector was operative during each fire drill for the entire time period reviewed.
These findings were reviewed with facility staff during the licensing.
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Plan of Correction
The Operations Manager will be responsible to check the lights on the smoke alarms and fire alarms to ensure they are operable on every fire drill conducted moving forward. Additionally, the form currently being used already asks if the alarms are operable, but staff has been marking N/A due to the exception request. Instead, the Operations Manager will complete the fire drill log accordingly by responding "Yes/No" where appropriate in place of "N/A" after checking the alarms. Staff is being informed on 2/16/18 during the staff meeting of this change. |
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 the review of 14 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 4 client records.
Client #2 was admitted to the partial hospitalization level of care on 10/25/17 and was an active client at the time of the inspection. There was documentation that the facility had billed the funding source for services provided prior to when the consent form to the funding source was signed and dated by the client on 11/30/17.
Client #4 was admitted to the partial hospitalization level of care on 3/22/17 and was discharged on 6/13/17. There was documentation that the facility communicated with the funding source on 3/22/17; however, the consent form to the funding source was not signed and dated until 3/23/17. Additionally, there was documentation that the facility communicated with a family member on 3/23/17; however, the consent form to the family member was not signed and dated until 3/28/17.
Client #5 was admitted to the partial hospitalization level of care on 9/6/17 and was discharged on 12/18/17. There was documentation that the facility had billed the funding source for services provided prior to when the consent form to the funding source was signed and dated by the client on 11/30/17.
Client #14 was admitted to the outpatient level of care on 11/21/17 and was an active client at the time of the inspection. There was documentation of a family counseling session with two family members on 1/17/18; however, only one family member had a consent form on file to attend the session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of correction moving forward is to have clients sign releases for the funding source on the day of admission and prior to calling the funding source.
Additionally, in place of verbal consent for family sessions, staff will obtain written informed and voluntary consent to release information for all collateral involved in the client's treatment prior to any sessions being conducted.
The facility director will be responsible to ensure the above gets completed and staff is being retrained on filling out the releases in their entirety as well as in a timely manner 2/16/18 during the staff meeting. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of 14 client records, 1 of 1 applicable record lacked documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate the client from treatment.
Client #8 was admitted to the outpatient level of care on 6/13/17 and was involuntarily discharged on 7/11/17.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
A form was developed on 2/15/18 to inform clients, when applicable, that they are being involuntarily terminated from treatment with a blank space to add in the reasoning. Additionally, the form includes a Yes/No section if the client wishes to appeal this decision. If the client chooses yes, the client has the opportunity to request reconsideration which is submitted to the facility director to either overturn the initial decision or keep it.
This is the facility director's responsibility to complete this form, when necessary, and meet with the client to discuss it and provide the opportunity to the client to reconsider this decision. Staff is being made aware of this form at the staff meeting 2/16/18. |
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
Based on a review of 14 client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in 4 of 7 applicable records reviewed.
Client # 3 was admitted to the partial hospitalization level of care on 12/13/17 and was still an active client at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of 12/18/17 and 2/4/18.
Client # 4 was admitted to the partial hospitalization level of care on 3/22/17 and was discharged on 6/13/17. There was no documentation of two counseling sessions per week for the duration of treatment.
Client # 6 was admitted to the partial hospitalization level of care on 4/5/17 and was discharged on 5/26/17. There was no documentation of two counseling sessions per week for the duration of treatment.
Client # 7 was admitted to the partial hospitalization level of care on 6/7/17 and was discharged on 8/21/17. Documentation of two individual sessions per week was not completed for the week of 8/14/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients admitted in to the partial hospitalization level of care will each see their counselor and/or Medical Director at least two times per week. The facility director will ensure that the clients are scheduled for their individual sessions twice a week in advance, so they are aware of their appointment with their counselor and/or the Medical Director more than a day in advance. Additionally, if they are unable to attend the scheduled sessions, arrangements will be made to reschedule within the same week to ensure the clients are getting individual counseling at least twice weekly. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of 14 client records, the facility failed to document a preliminary treatment plan in 2 of 7 applicable client records.
Client #8 was admitted to the outpatient level of care on 6/13/17 and was discharged on 7/11/17.
Client #9 was admitted to the outpatient level of care on 12/19/17 and was discharged on 1/5/18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of inspection, instead of creating new preliminary treatment and rehabilitation plans, staff was completing a treatment plan review for the reasoning in transferring to a lower level of care. Moving forward, when a client is discharged from partial hospitalization and admitted into the outpatient level of care, the staff will create a new preliminary treatment and rehabilitation plan with the client. The facility director will be responsible in ensuring the clinical staff is doing this when the client admits in to the outpatient level of care. Staff will be retrained on the new process at the staff meeting 2/16/2018. |
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 14 client records, 2 of 5 applicable records were missing the frequency of treatment and rehabilitation services on the comprehensive treatment plan.
Client #11 was admitted to the outpatient level of care on 10/30/17 and was discharged on 12/29/17. The comprehensive treatment plan was signed on 11/10/17.
Client #14 was admitted to the outpatient level of care 11/21/17 and was still active at the time of the inspection. The comprehensive treatment plan was signed on 12/15/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, all comprehensive treatment plans will include the type and frequency of treatment and rehabilitation services. The facility director is responsible for ensuring this information is inputted into the treatment plan both accurately and timely. The clinical staff is being retrained on the importance of entering this information when developing with the client during the staff meeting 2/16/18. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of 14 client records, 2 of 5 applicable clients did not receive counseling sessions according to the individual's comprehensive treatment plan.
Client # 12 was admitted to the outpatient level of care on 5/29/17 and was still an active client at the time of the inspection. The treatment plans signed on 7/17/17 and 9/29/17, indicated two individual sessions per week and 5 groups sessions per week; however, no individual sessions have been documented since 7/14/17.
Client # 13 was admitted to the outpatient level of care on 8/21/17 and was still an active client at the time of the inspection. The comprehensive treatment plan signed on 9/8/17, indicated two individual sessions per week and 23 groups sessions per week; however, only 1 individual session per week was documented and only 55 group sessions were documented from 09/01/17 through the date of the 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 retrain the staff on the importance of accuracy in the treatment plan and that each client receives the counseling services according to the individual treatment and rehabilitation plan. The facility director is responsible to retrain the staff on requirements for outpatient treatment and rehabilitation services within the treatment and rehabilitation plan, the importance of accuracy within said plan, the importance of delivering the services accordingly, and the review of all plans upon completion. This staff training will be held during the staff meeting 2/16/18. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of 14 client records, the facility failed to provide a complete client record in 4 of 7 applicable client records.
Client #8 was admitted to the outpatient level of care on 6/13/17 and was discharged on 7/11/17. There was no follow-up information in the record as of the date of the inspection.
Client #9 was admitted to the outpatient level of care on 12/19/17 and was discharged on 1/5/18. There was no follow-up information in the record as of the date of the inspection.
Client #10 was admitted to the outpatient level of care on 6/21//17 and was discharged on 8/17/17. There was no follow-up information in the record as of the date of the inspection.
Client #11 was admitted to the outpatient level of care on 10/30/17 and was discharged on 12/29/17. There was no follow-up information in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 1st, we updated our electronic medical record to include a post-discharge survey for our follow up phone calls that we did not have previously. Unfortunately, the follow ups that were done in the past were not documented accordingly. Moving forward, our Administrative Assistant will be making all follow up calls to clients and having them complete a survey within the electronic medical record. This staff member will also be inputting notes in to the system in the event he/she gets in touch with the client or needs to leave a message. The note in the system will include a summary of the follow up phone call. The facility director is responsible for overseeing this and ensuring it is getting done accordingly. |