INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2021 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee # 6 was hired as a counselor on January 13, 2020 and was due to have HIV/AIDS training and TB/STD training no later than January 13, 2021. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Administrator has been aware that one employee due for HIV/AIDS and TB/STD Training was incomplete. This employee had many unsuccessful attempts in trying to register for a DDAP approved course, as evidenced by the correspondence shown to the inspector during the pre-submission inspection due to the pandemic.
Since then, this employee has successfully registered for virtual courses to fulfill this requirement.
The Facility Director is responsible for ensuring that all counselors receive at minimum 6 hours of HIV/ADS training and at least 4 hours of TB/STD training with a DDAP approved curriculum within one year of hire for counselors and within 2 years of hire for all other staff. All other employees are currently compliant with this regulation. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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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 two of fourteen client records reviewed.
Client # 3 was admitted to the partial hospitalization activity on June 18, 2020 and was discharged on January 31, 2021. The record contained a consent to release information form to an employer, signed and dated by the client on June 18, 2020, that allowed for the release of treatment plans, psychological assessment, psychiatric history and evaluation, results of physical exam, medical history/current status, biopsychosocial assessment, lab 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 February 1, 2021 and was still active at the time of the inspection. The record contained a consent to release information form to an employer, signed and dated by the client on June 18, 2020, that allowed for the release of treatment plans, psychological assessment, psychiatric history and evaluation, results of physical exam, medical history/current status, biopsychosocial assessment, lab 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.
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 to employers to ensure that what is released is specific to what the code allows: only whether the client has or is receiving treatment. 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, #6. The electronic medical record utilized at the facility has been updated to have a standard release for Employers which restricts all information being disclosed with the exception of whether the client has or is receiving treatment.
Client #3 and #10 has signed a new Release of Confidential Information for their employer. All other current patient records have been reviewed and no other charts were out of compliance with this regulation. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in ten of fourteen client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on July 28, 2020 and was discharged on December 14, 2020. Release of information forms to a family member, another treatment provider, and a funding source were signed by the client and witness on July 29, 2020, but there was no documentation that a copy of any of the consent forms were offered to the client.
Client # 2 was admitted to the partial hospitalization activity on October 15, 2020 and was discharged on January 17, 2021. The release of information form to an external individual was signed by the client and witness on October 26, 2020, but there was no documentation that a copy of the consent form was offered to the client.
Client # 3 was admitted to the partial hospitalization activity on June 18, 2020 and was discharged on January 31, 2021 The release of information form to another treatment provider was signed by the client and witness on June 18, 2020, but there was no documentation that a copy of the consent form was offered to the client.
Client # 5 was admitted to the partial hospitalization activity on July 16, 2020 and was still active at the time of the inspection. The release of information forms to a medical practice and a friend of the client were signed by the client and witness on October 23, 2020, but there was no documentation that a copy of either of the consent forms were offered to the client.
Client # 8 was admitted to the outpatient activity on December 15, 2020 and was still active at the time of the inspection. The release of information forms to a family member, another treatment provider and the funding source were signed by the client and witness on July 29, 2020, but there was no documentation that a copy of any of the consent forms were offered to the client.
Client # 9 was admitted to the outpatient activity on January 18, 2021 and was still active at the time of the inspection. The release of information form to an external individual was signed by the client and witness on October 26, 2020, but there was no documentation that a copy of any of the consent forms were offered to the client.
Client # 10 was admitted to the outpatient activity on February 1, 2020 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the client and witness on June 18, 2020, but there was no documentation that a copy of the consent form was offered to the client.
Client # 11 was admitted to the outpatient activity on February 4, 2021 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client and witness on February 4, 2021, but there was no documentation that a copy of the consent form was offered to the client.
Client # 12 was admitted to the outpatient activity on October 19, 2020 and was discharged on February 3, 2021. The release of information forms to another treatment provider and family members were signed by the client and witness on July 22, 2020 and July 23, 2020, but there was no documentation that a copy of either of the consent forms were offered to the client.
Client # 14 was admitted to the outpatient activity on April 13, 2020 and was discharged on July 27, 2020. The release of information forms to another treatment provider and the funding source were signed by the client and witness on April 13, 2020, but there was no documentation that a copy of either of the consent forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has retrained staff on the importance of complete and accurate documentation, including the release of confidential information including that the client was offered a copy of the consent form. All releases for active patients will be resigned with this information recorded. The Quality Assurance Liaison is responsible for ensuring that all staff continue to check off that a client was offered a copy of the consent form. |