INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2026 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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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 a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project and the notification must also include the reason for termination in one of two applicable client records reviewed.
Client # 6 was admitted to the partial hospitalization activity on March 10, 2025 and was administratively discharged on April 9, 2025. There was no documentation in the record indicating the client was provided with written notification of the facility's decision to involuntarily terminate the client from treatment at the time of discharge. There was written documentation, in the record, of the facility's decision to involuntarily terminate the client's treatment, but the documentation was completed on January 6, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director in collaboration with the clinicians are responsible for ensuring that a patient that is being involuntary terminated have the right to be notified of the reason why and appeal the facility's decision. This is to be documented in the EMR using the form titled "Notification of Termination" at the time of discharge. The Quality Assurance liaison is responsible for auditing charts on a regular basis to ensure records are complete, timely, and accurate and escalates any discrepancies to facility leadership. A comprehensive retrain was conducted by the corporate team for the facility staff on 1/13/26 to review required timelines. |
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 ensure individual treatment and rehabilitation plans were developed and completed with the client, and per facility policy, in three of seven applicable client records reviewed.
The facility policy and procedure manual stated the individual treatment and rehabilitation plan is to be completed within 7 days of admission.
Client # 2 was admitted to the partial hospitalization activity on December 17, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by December 24, 2025; however, the plan was not completed until January 5, 2026.
Client # 4 was admitted to the partial hospitalization activity on August 14, 2025 and was discharged on September 18, 2025. The individual treatment and rehabilitation plan was due to be completed by August 21, 2025; however, the plan was not completed until August 25, 2025.
Client # 7 was admitted to the partial hospitalization activity on April 4, 2025 and was discharged on May 9, 2025. The individual treatment and rehabilitation plan was due to be completed by April 11, 2025; however, the plan was not completed until April 30, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinicians are responsible for ensuring that all documentation in their assigned caseload are completed timely, which include preliminary treatment plans and individual treatment and rehabilitation plans. The QA Liaison is responsible for ongoing auditing of the charts and each week sends out an email to each clinician with outstanding items. The Facility Director is responsible for ensuring the team follows through on these audits. A comprehensive retrain was conducted by the corporate team for the facility staff on 1/13/26 to review required timelines. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in one of two applicable client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on September 17, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 22, 2025 and the first update was due no later than October 22, 2025; however, the update was completed on November 5, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinicians are responsible for ensuring that all documentation in their assigned caseload are completed timely, which include treatment plan reviews. The QA Liaison is responsible for ongoing auditing of the charts and each week sends out an email to each clinician with outstanding items. The Facility Director is responsible for ensuring the team follows through on these audits. A comprehensive retrain was conducted by the corporate team for the facility staff on 1/13/26 to review required timelines. |
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 client records, the facility failed to document a preliminary treatment and rehabilitation plan, as part of their intake process and per facility policy, in six of seven applicable client records reviewed.
The facility policy and procedure manual stated that the preliminary treatment and rehabilitation plan is to be completed within 72 hours of admission.
Client # 8 was admitted to the outpatient activity on September 18, 2025 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due to be completed by September 21, 2025; however, the preliminary plan was not completed until November 21, 2025.
Client # 9 was admitted to the outpatient activity on September 24, 2025 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due to be completed by September 27, 2025; however, the preliminary plan was not completed until December 4, 2025.
Client # 10 was admitted to the outpatient activity on October 14, 2025 and was still active at the time of the inspection. The preliminary treatment and rehabilitation plan was due to be completed by October 17, 2025; however, the preliminary plan was not completed until October 30, 2025.
Client # 11 was admitted to the outpatient activity on May 9, 2025 and was discharged on July 23, 2025. The preliminary treatment and rehabilitation plan was due to be completed by May 12, 2025; however, the preliminary plan was not completed until August 4, 2025, after the client was discharged.
Client # 12 was admitted to the outpatient activity on May 6, 2025 and was discharged on October 6, 2025. The preliminary treatment and rehabilitation plan was due to be completed by May 9, 2025; however, the preliminary plan was not completed until June 19, 2025.
Client # 13 was admitted to the outpatient activity on May 13, 2025 and was discharged on September 16, 2025. The preliminary treatment and rehabilitation plan was due to be completed by May 16, 2025; however, the preliminary plan was not completed until May 28, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinicians are responsible for ensuring that all documentation in their assigned caseload are completed timely, which include preliminary treatment plans and individual treatment and rehabilitation plans. The QA Liaison is responsible for ongoing auditing of the charts and each week sends out an email to each clinician with outstanding items. The Facility Director is responsible for ensuring the team follows through on these audits. A comprehensive retrain was conducted by the corporate team for the facility staff on 1/13/26 to review required timelines. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were developed and completed with the client per facility policy, in six of seven applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 7 days of admission.
Client # 8 was admitted to the outpatient activity on September 18, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by September 25, 2025; however, the plan was not completed until November 21, 2025.
Client # 9 was admitted to the outpatient activity on September 24, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 1, 2025; however, the plan was not completed until November 6, 2025.
Client # 10 was admitted to the outpatient activity on October 14, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by October 21, 2025; however, the plan was not completed until December 7, 2025.
Client # 11 was admitted to the outpatient activity on May 9, 2025 and was discharged on July 23, 2025. The individual treatment and rehabilitation plan was due to be completed by May 16, 2025; however, the plan was not completed until June 12, 2025.
Client # 12 was admitted to the outpatient activity on May 6, 2025 and was discharged on October 6, 2025. The individual treatment and rehabilitation plan was due to be completed by May 13, 2025; however, the plan was not completed until June 19, 2025.
Client # 14 was admitted to the outpatient activity on February 20, 2025 and was discharged on May 28, 2025. The individual treatment and rehabilitation plan was due to be completed by February 27, 2025; however, the plan was not completed until March 7, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinicians are responsible for ensuring that all documentation in their assigned caseload are completed timely, which include preliminary treatment plans and individual treatment and rehabilitation plans. The QA Liaison is responsible for ongoing auditing of the charts and each week sends out an email to each clinician with outstanding items. The Facility Director is responsible for ensuring the team follows through on these audits. A comprehensive retrain was conducted by the corporate team for the facility staff on 1/13/26 to review required timelines. |