INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2023 through March 9, 2023 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 Lake Ariel, 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 and the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of two applicable personnel records reviewed.
Employee #7 was hired as a BHT on February 6, 2020 and was due to have the HIV/AIDS training no later than February 6, 2022. The HIV/AIDS training was not completed at the time of the inspection.
Employee #8 was hired as the operations manager on November 20, 2020 and was due to have the TB/STD training no later than November 20, 2022. The TB/STD training was not completed at the time of the inspection.
This is a repeat citation from the August 11, 2022 annual licensure inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Administrator is responsible for ensuring that all counselors receive at minimum 6 hours of HIV/ADS and 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. Employees continue to struggle with signing up through the training website. The Director of Clinical Development and Corporate Medical Director are working to create training courses with DDAP approved curriculum to ensure that all employees, including these individuals, obtain the required hours for HIV/AIDS and TB/STD training. All other employees are currently compliant with this regulation. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, conducted on March 9, 2023, the facility failed to keep the exterior of the building and the building grounds or yard free of hazards.
The driveway, leading up to the facility, had deep potholes in the middle of the driveway, creating a safety hazard for people walking along the driveway and for vehicles entering the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has approved for the driveway leading into the facility to be paved to avoid safety hazards for people walking along the driveway and for vehicles entering the facility. The business office is in the process of obtaining quotes from contractors so paving can be underway. The Operations Manager is responsible for reporting any findings of hazards of the exterior and interior of the building including the grounds during their monthly assessments of the physical plant. Reporting of any findings will occur immediately to the Administrator so the identified hazards can be immediately mitigated. |
709.82(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in two of two applicable client records reviewed.
Client # 15 was admitted into the partial hospitalization activity on January 6, 2023 and was discharged on February 3, 2023. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
Client # 16 was admitted into the partial hospitalization activity on February 2, 2023 and was discharged on February 8, 2023. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all client charts are in compliance, including treatment and rehabilitation plans in each level of care they are being treated for. The facility has reimplemented its 'caseload tracker' that identifies needs in the patient records, including treatment and rehabilitation plans in the partial hospitalization level of care. The Facility Director is responsible for reviewing the caseload tracker and all charts. The Facility Director will review charts on a weekly basis to ensure that all patient records have the required documentation in them on any given day. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which is to include case consultation notes, in one of two applicable client records reviewed.
Client # 15 was admitted into the partial hospitalization program on January 6, 2023 and was discharged on February 3, 2023. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all client charts are in compliance, including case consultation notes in each level of care they are being treated for. The facility has reimplemented its 'caseload tracker' that identifies needs in the patient records, including case consultation notes in the partial hospitalization level of care. The Facility Director is responsible for reviewing the caseload tracker and all charts. The Facility Director will review charts on a weekly basis to ensure that all patient records have the required documentation in them on any given day. |