INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2024 through January 30, 2024 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 at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in six of nine applicable personnel records reviewed.
Employee # 2 was hired as a counselor on April 18, 2022 and was due to have the TB/STD training no later than April 18. 2023. The TB/STD training was not completed at the time of the inspection.
Employee # 3 was hired as a counselor on July 12, 2022 and was due to have the TB/STD training no later than July 12, 2023. The TB/STD training was not completed at the time of the inspection.
Employee # 6 was hired as a BHT on December 13, 2021 and was due to have the HIV/AIDS and TB/STD trainings no later than December 13, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 7 was hired as a BHT on August 23, 2021 and was due to have the HIV/AIDS and TB/STD trainings no later than August 23, 2023. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 8 was hired as a maintenance worker on February 5, 2020 and was due to have the HIV/AIDS and TB/STD trainings no later than February 5, 2022. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 9 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.
This is a repeat citation from the August 11, 2022 and the March 9, 2023 annual licensing inspections.
These findings were 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/AIDS 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 Medical 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 TB/STD training. DA-Training has scheduled a TB/STD training for Avenues staff on June 12th. The HIV/AIDS training module that is now available is being utilized and all outstanding employees will take this course in the next 90 days. All other employees are currently compliant with this regulation. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client records reviewed.
Per the requirement in Licensing Alert 02-21 and the facility's policy, the emergency contact is to be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 7 was admitted to the inpatient non-hospital detoxification activity on July 19, 2023 and was discharged against medical advice on July 26, 2023. There was no documentation that the emergency contact was notified of the client's discharge 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 Administrator is responsible for ensuring all clients who leave against medical advice have documentation in their medical record to show the emergency contact was notified within 12 hours. The form staff was using in the EMR had confusing terminology and staff were recording their supervisor. The form in the system was updated day of inspection to incorporate Emergency Contact notification. This was discussed with all staff on 1/30/24. |
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 completed and developed with the client in two of two applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within seven days of admission.
Client # 15 was admitted to the partial hospitalization activity on September 11, 2023 and was discharged on September 19, 2023. The individual treatment and rehabilitation plan was due to be completed no later than September 18, 2023; however, the plan was not completed prior to discharge.
Client # 17 was admitted to the partial hospitalization activity on November 26, 2023 and was discharged on December 21, 2023. The individual treatment and rehabilitation plan was due to be completed no later than December 3, 2023; however, the plan completed on December 13, 2023.
This is a repeat citation from the March 9, 2023 annual licensing inspection.
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 individual treatment and rehabilitation plans. The team was notified of the findings from this survey and reiterated the importance of timely documentation to prevent this in the future. Since inspection, a QA Liaison was hired. The QA Liaison is responsible for ongoing auditing of the charts and each week will send out an email to each clinician with outstanding items. The Facility Director is responsible for ensuring the team follows through on these audits and to utilize the QA Liaison audits on a regular basis to assist with time management. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 completed and developed with the client in three of five applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within seven days of admission.
Client # 8 was admitted to the inpatient non-hospital activity on January 3, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than January 10, 2024; however, the plan was completed on January 24, 2024.
Client # 9 was admitted to the inpatient non-hospital activity on December 24, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than December 31, 2023; however, the plan was completed on January 29, 2024.
Client # 10 was admitted to the inpatient non-hospital activity on January 3, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than January 10, 2024; however, the plan was not completed 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
The clinicians are responsible for ensuring that all documentation in their assigned caseload are completed timely, which include individual treatment and rehabilitation plans. The team was notified of the findings from this survey and reiterated the importance of timely documentation to prevent this in the future. Since inspection, a QA Liaison was hired. The QA Liaison is responsible for ongoing auditing of the charts and each week will send out an email to each clinician with outstanding items. The Facility Director is responsible for ensuring the team follows through on these audits and to utilize the QA Liaison audits on a regular basis to assist with time management. Client #10 now has a treatment and and rehabilitation plan. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing 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 training within the regulatory timeframe was submitted and approved by the Department for the August 11, 2022 and March 9, 2023 annual licensing inspections. Failing 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 training within the regulatory timeframe was again found to be a deficiency in the January 3, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrator and Facility Director are responsible for ensuring that all plan of corrections submitted from previous inspection results are followed through to ensure ongoing compliance in deficient areas. The Administrator is responsible for ensuring all plan of corrections are followed for administrative deficiencies and the Facility Director is responsible for ensuring all plan of corrections are followed for clinical/medical/charting deficiencies. The Facility Director will utilize the newly hired QA Specialist to ensure any clinical plan of corrections submitted are being upheld on an ongoing basis. The Administrator and Director of Compliance will meet monthly to ensure compliance is achieved in all administrative aspects of any plan of corrections that have been submitted to the Department. |