INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on January 6, 2021 through January 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of twenty-two client records reviewed.
Client #14 was admitted into the detoxification level of care on June 30, 2020 and was discharged on July 6, 2020. There was a phone contact between facility staff and law enforcement documented on July 5, 2020; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Per this organization's policies, a release of confidential information is to be signed by both patient and witness prior to the disclosure of any information about a patient. The Clinical Director is responsible for ensuring that all patients whom information is being disclosed on has a signed and active release of information in the patient's record. Staff meeting held on 1/7/2021 addressed this with staff and reiterating the importance of patient confidentiality as protected under HIPAA, 42 CFR Part 2, and PA Code 255.5. Review of charts showed no other patients are out of compliance with federal and state regulations. The Clinical Director is responsible for regular chart reviews on a weekly basis to prevent this from happening again. |
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
The facility failed to ensure that counseling services are provided on a regularly, scheduled basis, particularly that individual counseling is to be provided at least twice per week, in three of five applicable client records reviewed.
Client #1 was admitted into the partial hospitalization level of care on December 21, 2020 and was still active at the time of the inspection. During the week of December 28, 2020, there were no scheduled or completed individual therapy sessions documented in the client record.
Client #2 was admitted into the partial hospitalization level of care on July 28, 2020 and was discharged on August 24, 2020. During the weeks of July 28, 2020, August 3, 2020, August 10, 2020, and August 17, 2020, there was only documentation of one individual session conducted per week in the client record.
Client #4 was admitted into the partial hospitalization level of care on August 6, 2020 and was discharged on September 5, 2020. During the weeks of August 10, 2020 and August 17, 2020, there was only documentation of one individual session conducted per week in the client record. Additionally, during the weeks of August 24, 2020 and August 31, 2020, there were no completed individual sessions documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director is responsible for oversight of clinical programming, including regular chart audits and review of charts to ensure that all patients admitted into the partial hospitalization program receive two individual sessions weekly. This was reviewed with all staff on 1/7/2021. As of 1/11/2021, a 'caseload tracker' has been mandated for all clinical staff to ensure they are compliant on a weekly basis. This chart tracker will be monitored by the Clinical Director as well as regular record reviews by the Clinical Director. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
The facility failed to maintain a complete client record on an individual, which is to include follow-up information, in two of four applicable client records reviewed.
Client #12 was admitted into the detoxification level of care on April 30, 2020 and was discharged on May 4, 2020. There was no documentation of follow-up information in the record as of the date of the inspection.
Client #13 was admitted into the detoxification level of care on August 7, 2020 and was discharged on August 12, 2020. There was no documentation of 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
The Executive Director is responsible to oversee the case management team for alumni engagement with all discharged patients, though, not specified in the organization's policies and procedures that we would not contact clients who left treatment prior to completion. The two clients identified were clients who left Against Medical Advice (AMA). The Director of Compliance is responsible for updating the programs policies and procedures to reflect that patients that leave AMA will not have documented follow up phone calls. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to obtain an informed, voluntary, written consent to treat with a narcotic agent signed by the patient, prior to the patient being administered the medication, in three of three applicable patient records reviewed.
Patient #14 was admitted into the detoxification level of care on June 30, 2020 and was discharged on July 6, 2020.
Patient #17 was admitted into the inpatient level of care on December 31, 2020 and was active at the time of the inspection.
Patient #18 was admitted into the inpatient level of care on January 1, 2021 and was active 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 organization was under the interpretation that clients on buprenorphine while in detoxification did not need an informed consent to treat with a narcotic agent since the requirements of the form include methadone and LAAM agents. Upon discussion with the licensing specialist, staff was explained the need for it. At the staff meeting held on 1/7/2021, this was reviewed with all medical staff and has been added to their admission workflow in which the medical director is responsible for oversight. As of 1/11/2021, an 'Informed Consent to Treat with Buprenorphine' has been added into this project's EMR. After a review of active charts, any clients that were prescribed buprenorphine as of 1/11/2021 have now signed this consent. |
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
The facility failed to include documentation of a preliminary treatment plan during the intake and admission period in one of three applicable client records reviewed.
Client #6 was admitted into the outpatient level of care on July 12, 2020 and was still active 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 Clinical Director is responsible for ensuring a complete and thoroughly documented patient record, in compliance with all applicable codes, regulations, and project policies and procedures. All clients who admit into the outpatient level of care will have a signed preliminary treatment plan during the admission process as outlined in the project's policies and procedures. This was also reviewed with the intake staff during staff meeting held 1/7/2021. |
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
The facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client in two of three applicable client records reviewed.
Client #7 was admitted into the outpatient level of care on December 8, 2020 and was still active at the time of the inspection. The record did not contain an outpatient treatment plan.
Client #8 was admitted into the outpatient level of care on December 13, 2020 and was discharged on January 1, 2021. The record did not contain an outpatient treatment plan for the entire duration of the treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When patients transition to lower levels of care, a new individualized treatment and rehabilitation plan will be created. During the staff meeting on 1/7/2021, the rationale behind the need for a new treatment plan was explained to them based on the change in intensity, frequency, etc. Continual chart oversight and the caseload tracker, overseen by the Clinical Director, mandated as of 1/11/2021, will ensure that this is not missed moving forward. The active patient that was missing an outpatient individualized treatment and rehabilitation plan will be rectified by 1/15/2021. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to ensure that all treatment and rehabilitation plans were reviewed and updated at least every sixty days in one of one applicable client record reviewed.
Client #6 was admitted into the outpatient level of care on July 12, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on July 19, 2020 with an update due no later than September 19, 2020; however, the update was completed on October 29, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This project's policies and procedures reflected a requirement of every 90 days for treatment plan reviews at the outpatient level of care. The Director of Compliance is responsible to update the policies and procedures to be in compliance with PA Code 711.92. This was discussed with staff on 1/7/2021 and the Clinical Director is responsible for ensuring that outpatient treatment plans are reviewed every 60 days through oversight of the caseload tracker and regular chart reviews. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
The facility failed to maintain a complete client record on an individual, which is to include documentation of case consultation notes, in one of one applicable client record reviewed.
Client #6 was admitted into the outpatient level of care on July 12, 2020 and was still active at the time of the inspection. There was no documented case consult notes for the entire duration of the treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case consultations were discussed with all staff on 1/7/2021. The Clinical Director is responsible for ensuring that all patients have case consultations while they are in treatment as a multidisciplinary team approach. The active patient that has not had a case consultation in his record will have one by 1/15/2021. The Clinical Director is responsible for oversight of the caseload tracker and chart reviews on a weekly basis to prevent this from happening in the future. |